Substances Flashcards
Triad of altered consciousness, respiratory depression, pinpoint pupils
Heroin intoxication
Hypertension, respiratory depression, bradycardia
Cushing’s reflex: coning of the brainstem
Distractability, insomnia, grandiosity, flight of ideas, activity increase (goal-directed), speech (extreme talkativeness), thoughtlessness (impulsive)
3 or more = manic episode and symptoms must last for 1 week
Anxiety, aggression, agitation, psychosis or delirium + mydriasis + change in vital signs
Amphetamine or cocaine (less psychotic features than amphetamine)
Common symptoms of stimulant intoxication = dilated pupils, hypertension, tachycardia
Heroin withdrawal
muscle spasms, joint pain, N/V, diarrhea and abdominal cramps, rhinorrhea and lacrimation, sweating
Amphetamine withdrawal symptoms?
depression, irritability, fatigue, increased appetite, psychomotor disturbance
what is the typical time frame for alcohol withdrawal to occur?
within 72 - 92 hours of cessation of drinking
what is the management of long term dependence on alcohol?
group/individual support therapy + counselling therapy
disulfiram
acamprosate
naltrexone
what are some of the mechanisms of the medications for long term dependence for alcohol?
disulfiram: inhibits ADH, leads to unpleasant effects of alcohol (flushing, tachycardia, hypotension), discouraging patient from drinking
acamprosate: GABA agonist and glutamate antagonist. reverses GABA and glutamate imbalances when abstaining from alcohol,
naltrexone: acts on opioid receptor of opioid antagonist. stops craving for alcohol.
what is the diagnostic criterion for alcohol withdrawal?
cessation of alcohol use that has been heavy and prolonged
2 or more of the following symptoms: tremors, irritability, insomnia, n/v, anxiety, psychomotor agitation, grand mal seizures, autonomic hyperactivity (anxiety, arousal, sweating, facial flushing, mydriasis, tachycardia, mild hypertension)
causing significant distress and impairing functioning
what is the treatment for alcoholic withdrawal?
diazepam 20mg oral, 2 hours until symptoms resolve
+ add thiamine 300mg IM/IV daily for 3 - 5 days then move on to oral 300mg daily for next weeks
what is the diagnostic criterion for delirium tremens
alcohol withdrawal syndrome + clouding of consciousness and confusion, visual hallucinations, marked tremor + other signs of autonomic instability - paranoid delusions, agitation, sleeplessness
what is the treatment for delirium tremens?
ideally prevention - starting diazepam 20mg oral upon withdrawal symptoms, every 2 hourly until symptoms subside
delirium tremens - high doses may be required that require specialist review
what is the triad of wernicke and korsakoff’s syndrome?
wernicke: ataxia, oculomotor dysfunction (6th nerve palsy, nystagmus), confusion
korsakoff’s syndrome: anterogade and retrogade amnesia + confabulation
what is the treatment of wernicke’s encephalopathy and korsakoff’s syndrome?
thiamine (b1) 100mg oral 2 times BD for 1 - 2 weeks.
korsakoff’s require a longer period of b1 for about 3 - 12 weeks
what are the symptoms of opioid intoxication?
(depressant) CNS depression GI dysmotility respiratory depression analgesia n/v slurred speech hypotension, bradycardia, pupillary constriction seizures (in overdose)
what are the symptoms of opioid overdose?
pinpoint pupils, respiratory depression, CNS depression (decreased HR, RR, LOC)
what are some common complications of opioid use?
HIV infection, hep b, hep c
sudden pulmonary oedema d/t opioid toxicity and respiratory depression
local abscess, venous thrombosis, myopathy
coma in overdose, cerebral oedema
perforation of nasal septum d/t repeated heroin sniffing
infective endocarditis (IV use)
peripheral nerve compression
what is the DSM 5 diagnostic criterion of opioid intoxication?
must have pupillary constriction LOC/drowsiness sluring of speech impairments in attention or memory psychological or behavioural changes that have arisen during or shortly after the usage
what is the DSM 5 diagnostric criterion of opioid withdrawal?
recent cesation of usage of opioid that was previously heavy or recent administraiton of an opioid antagonist
3 of the following developing within minutes to several days of criterion:
mood changes
Gi disturbances which cause n/v/d
muscular aches
lacrimination or rhinorrhea
pupillary dilatation, piloerection, sweatin g
what are the common symptoms of opioid withdrawal?
(reverse of depresant effects) n/v/d increased vital signs dilated pupils sweating, hot and cold flushes piloerection, tremor, restlessness muscle aches, abdominal cramping
what are the common symptoms of opioid withdrawal?
(reverse of depresant effects) n/v/d increased vital signs dilated pupils sweating, hot and cold flushes piloerection, tremor, restlessness muscle aches, abdominal cramping
Naloxone needs to be titrated when administered for opioid intoxication because?
if not titrated, can precipitate withdrawal and sudden reversal can lead to MI in elderly or CAD, agitated delirium
Naloxone needs to be titrated when administered for opioid intoxication because?
if not titrated, can precipitate withdrawal and sudden reversal can lead to MI in elderly or CAD, agitated delirium
what is the treatment of heroin overdoses?
one dose of naloxone stat dose (because heroin is a short acting opioid - similar pethidine, fentanyl, immediate release morphine)
if long acting (such as methadone, or slow release formulations) - naloxone infusion is required after initial bolus
what is the treatment for opioid withdrawal symptoms?
buprenorphine (partial agonist)
diazepam for anxiety and agitation - only prescribed if supervision is available as dependence/fatal overdose issue
what is the long term treatment for opioid dependence
psychotherapy: counselling, CBT, social support
maintanance treatment; buprenorphine or methadone
what is the differences between the usage of buprenorphine and methadone?
buprenorphine; partial agonist, has lower risk of OD and physical dependence
methadone; full agonist, better outcome if provided for long periods, may cause QT prolongation
what is the pharmaco treatment of heroin overdoses?
one dose of naloxone stat dose (because heroin is a short acting opioid - similar pethidine, fentanyl, immediate release morphine)
if long acting (such as methadone, or slow release formulations) - naloxone infusion is required after initial bolus
what is the differences between the usage of buprenorphine and methadone?
buprenorphine; partial agonist, has lower risk of OD and physical dependence
methadone; full agonist, better outcome if provided for long periods, may cause QT prolongation
what are some methods of opioid administration?
IV
IM
intranasal
subcut
what is the management strategy of acute opioid intoxication
icu admission + support; in particular respiratory rate, airway, and circulation naloxone administration (50 - 200mcg IV bolus titrated to clinical effect every 2 - 3 minutes)
what is the management strategy of acute opioid intoxication
icu admission + support; in particular respiratory rate, airway, and circulation naloxone administration (50 - 200mcg IV bolus titrated to clinical effect every 2 - 3 minutes)
what are the symptoms of BDZ withdrawal?
tremors, anxiety, perceptual disturbances (visual hallucinations), dysphoria, psychosis, seizures, hyperacusis, photophobia, palpitations
what is the treatement for BDZ withdrawal?
diazepam 20mg orally every 2 hours, until withdrawal symptoms are controlled, gradually taper over a course of few months
what is the prevention for BDZ withdrawal?
use of BDZ with long half life (diazepam, chlordiazepoxide) and a gradual tapering of the patient’s BDZ over a course of several months
what are the symptoms of isolated BDZ overdose?
CNS depression w/ normal vitals. usually arousable and able to provide an adequate history.
patient w/ isolated BDZ overdose rarely cause significant toxicity, only when co-ingested w/ opioid and ETOH does that occur
what are the investigations for BDZ use?
screening for metabolites of 1, 4 - benzodiazepines. it does not detect clonazepam, lorazepam, midazolam, alprazolam. can be detected as early as 3 hours and remain detectable for up to 2 weeks.
urine testing; up to 3 days after use, can only detect about 6 - 8 hours after drug use (not for current use)
hair testing; requires 2 weeks
sweat testing; requires 7 days
serum testing: dectable for 6 - 48 hours
what are the intoxication symptoms of cocaine use?
psychological effects: anxiety and irritability, panic attacks, suspiciousness and paranoia, grandiosity and impaired judgement, psychotic symptoms such as delusions and hallucinations, sleep disturbances
behavioural effects: restlessness, agitation, tremor, dyskinesia, repetitive or stereotyped behaviours such as picking at the skin
physiological: tachycardia, pupil dilation, diaphoresis, nausea
what are the withdrawal symptoms of cocaine use?
will have initial period of intense symptoms: psychomotor retardation, severe depression w/ suicidal ideation
depression, anxiety, fatigue, difficulty concentrating, hypersomnia, difficulty experiencing pleasure (anhedonia), increased appetite
what are the withdrawal symptoms of cocaine use?
will have initial period of intense symptoms: psychomotor retardation, severe depression w/ suicidal ideation
depression, anxiety, fatigue, difficulty concentrating, hypersomnia, difficulty experiencing pleasure (anhedonia), increased appetite
what is the treatment of cocaine withdrawal?
supportive treatment: allow patient to sleep and eat as needed in a supportive environment
use a short acting BDZ, anti-depressant if persistent depression or suicidal ideation
what is the treatment of cocaine withdrawal?
supportive treatment: allow patient to sleep and eat as needed in a supportive environment
use a short acting BDZ, anti-depressant if persistent depression or suicidal ideation
what is the treatment of chronic cocaine use disorder?
psychosocial treatment: motivational interviewing, psychodynamic, CBT including relapse prevention and contingency management
continuing care within the community w/ substance abuse treatment programme
what is the treatment for BDZ withdrawal?
diazepam 20mg orally every 2 hours, until withdrawal symptoms are controlled, gradually taper over a course of few months
what is the treatment of chronic cocaine use disorder?
psychosocial treatment: motivational interviewing, psychodynamic, CBT including relapse prevention and contingency management
continuing care within the community w/ substance abuse treatment programme
what is the treatment for acute BZD overdose?
supportive care: most importantly to mantain airway patency, respiratory support, give O2 (d/t respiratory depression)
what is the treatment for opioid withdrawal symptoms?
buprenorphine (partial agonist): 4 - 8 mg sublingually as single dose 1st day, and increasing to 12 mg as single dose on 3rd day then decreasing over the next 2 - 5 days
diazepam for anxiety and agitation - only prescribed if supervision is available as dependence/fatal overdose issue
what is the management strategy of acute opioid intoxication
icu admission + support - in particular respiratory rate, protection of airway, and circulation naloxone administration (50 - 200mcg IV bolus titrated to clinical effect every 2 - 3 minutes)
what levels of alcohol for non alcohol tolerant person to start impairing function?
20 - 30 mg/dL
alcohol tolerant person - may be higher at 150mg/dL
what are the symptoms of severe opiate intoxication?
pinpoint pupils, respiratory depression, CNS depression (stupor, coma)
what are the effects of alcohol on sleep?
helps make sleep easier, reduces deep sleep, REM sleep, and makes sleep more fragmented
what are the signs and symptoms of alcohol withdrawal?
coarse tremors, insomnia, anxiety, agitation, and autonomic hyperactivity. this can be made worse and accompanied by severe agitation, confusion, tactile/visual hallucinations.
treatment of alcohol withdrawal?
diazepam (20mg, 2 hourly until symptoms resolve) + thiamine 100mg.
features of caffeine withdrawal?
usually after 1 day, severe headache, fatigue, and subjective loss of concentration
based on DSM- 5, what is the definition of substance use disorder?
for 12 months, at least 2 of the following: tolerance or withdrawal symptoms no control need to cut down loses time craves failed roles helpless trades off
what are the signs and symptoms of alcohol intoxication
slurred speech incoordination unsteady gait stupor/coma impairment in attention or memory nystagmus
what is the signs and symptoms of cannabis intoxication
conjunctival injection and dry mouth
increased appetite
euphoria and heightened senses
nystagmus/ataxia
what are the signs and symptoms of cannbis withdrawal
agitation/anger/aggression
anxiety/irritability/restlessness
insomnia
