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Flashcards in 14 - Drugs of Abuse Deck (64):
1

Use disorder – DSM V

- Use more than planned
- Worry about cutting back or unsuccessful
- Lots of time using or recovering or getting
- Craving
- Life is affected
- Continued to use even though life is affected
- Risky behaviors
- Tolerance
- Withdrawal

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Mild, moderate, severe substance disorder

- A mild substance use disorder is suggested by the presence of 2-3 symptoms
- Moderate by 4-5 symptoms
- Severe by 6 or more symptoms
- No longer trying to sort out addiction (which is physical) from abuse, but defining much how it affects person’s life

3

Various drugs

- Stimulants
- Benzodiazepines
- Opioids
- Hallucinogens
- Dissociative drugs
- Marijuana
- Solvents/Inhalants
- Alcohol

4

Stimulants

- Nicotine
- Caffeine
- Cocaine
- Amphetamines

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How stimulants work

- Release DA and NE

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Stimulants route of administration

- Oral = Slow onset, low potency, no “rush”
- Intranasal = Faster onset
- Intravenous = Faster onset, “rush”
- Smoking = Fastest onset, most addictive

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Stimulant effects (low to moderate doses)

- Insomnia
- Increased endurance
- Increased activity
- Euphoria and mood enhancing

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Stimulant effects (high doses)

- Paranoia
- Hallucinations
- Suspiciousness
- delusions
- Picking
- Pancreatitis/DM

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Stimulant: Other negative effects

- Stroke
- Seizures
- MI
- Psychotic Symptoms
- Lung and Nasal problems

10

Cocaine

- Blow, coke, crack, rock, snow
- Snort or rub on gums
- Crack is heated and inhaled or injected

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Biggest worry

- MI – 1% of all MIs – increases plaque formation and causes vasospasm
- Don’t use Beta Blocker if concerned of cocaine use
- Can cause issues with nose, lungs

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Amphetamine (speed)

Methamphetamine
o Added methyl to facilitate crossing the blood-brain barrier
o Ice or crystal meth is the crystalized form
o Crank is made in home labs

Amphetamines
o Better oral absorption than cocaine and longer duration than cocaine

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Snorting Adderall

- Pulmonary talcosis
- Manufacturers use talc as a binder

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Stimulants: Withdrawal and Dependence

3 stages of Abstinence:
o 1-5 days: “crash” with intense craving, exhaustion, and intense depression
o 1-10 weeks: “withdrawal” depression, craving, hedonic state (relapse is strong)
o Indefinite: occasional depression, moderate craving, loss of pleasure

Withdrawal and dependence:
o Depression
o Fatigue
o Hunger
o Aches and pain
o Loss of pleasure

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These help with stimulant withdrawal

- Benzos
- SSRIs – need careful monitoring
- Anti-psychotics

16

Smoking

- About 18% of the adult population now
- Very fast acting (very addictive)
- DA release
- Also the physical habit

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Why you don’t want your patient smoking?

- Increased risk of death
- Increased risk of heart/lung issue
- Anesthesia
- Poor circulation means poor healing

18

Quitting smoking

- About ½ of smokers tried to quit for at least 1 day in previous year
- 7 meds FDA approved to help (Chantix, Zyban, replacements)
- Cold turkey about 4%
- CBT
- ***Trying 2 or more methods at once helpful***

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Benzodiazepines (benzos)

- Depressant effect on CNS by sitting on GABA receptor and stimulating GABA
- Used to relieve anxiety, muscle relaxation and to treat seizures
- Addictive
- Will reset the “anxiety” level in the brain over time

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***BENZOS*** KNOW THIS

- Can be dangerous with ETOH
- Fast withdrawal maybe fatal – weaning and close supervision if prolonged use and high doses.
- Romazicon 0.2ml IV – use with caution and be prepared!!! Seizures possible

21

Opioid examples

Examples:
- Heroin, morphine, codeine, oxycodone, hydromorphone, hydrocodone, fentanyl, oxymorphone, tramadol (yes tramadol), Dilaudid and others
- Morphine-like effects by binding to brain opioid receptors

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Opioid effects

- Change in mood
- Mental clouding
- Slow breathing
- Sleepiness
- Analgesia
- Constipation
- Urinary retention
- Withdrawal not life threatening

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Opioid withdrawal symptoms

- Irritable, agitated, anxious
- Pain
- Sweaty
- Nausea

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Help with opioid withdrawal

- Can get them on “safer” opioid – methadone
- Wean
- Benzos
- Zofran
- Clonidine
- Suboxone (mix of narcotic and naltrexone)

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Opioid reversal agent

- IV – Narcan (they may come up swinging)
- Oral – naltrexone – many other uses

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Prescribing opioids long term

- UDS, PMP
- Have goals
- Try to cut back, use non-opioid therapies, contracts

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Hallucinogens

- Psychedelics
- Alter consciousness
- Abuse leads to cardiovascular and respiratory collapse
- Synthetic Hallucinogens: LSD, peyote
- Long term flash backs, paranoia

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Dissociative anesthetics

- PCP and Ketamine - Sense of timelessness (being dead, not having limbs, floating in space), depersonalization
- High doses DXM
- Nitrous Oxide
- NMDA/glutamate complex antagonized - Can cause depression leading to suicide, or self-inflicted wounds or violence
- Profound anesthesia

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***Dissociative Desired Effects***

- Dreamy and carefree state, altered perception, mood elevation
- ***Perceptual distortions, diminished pain sensitivity, depersonalization
- ***Ketamine being used in trauma

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Dissociative undesired effects

- Mood swings, partial amnesia, and impaired judgement, disorientation, preoccupation with abnormal body sensations, amnesia, nystagmus, panic, motor impairment, and confusion, catatonia, delirium, psychotic behavior, hypertensive crisis, severe motor impairment…death

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Dissociative PCP treatment if out of control

- Isolate patient with restraints
- Haldol
- Valium
- Acidify urine

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Marijuana

- Cannaboid receptors all over the body (not just brain)

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Medical uses of marijuana

- Glaucoma
- Muscle spasms
- Seizures
- Nausea/appetite
- Insomnia
- Pain

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Marijuana: Starting Young and IQ

- Duke Study
- Weekly use before age 18 – lose 8 IQ points
- Potentially someone in 50th percentile now the 29th
- Less likely to get educated after high school

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Marijuana drug

- Active ingredient in cannabis is THC
- Impairs motor coordination and perception
- About 9-15% addictive (younger you start more addictive)
- Mild withdrawal symptoms that last 1 to 2 weeks if big user

36

Solvents and inhalants

- Volatile intoxicants, anesthetics
- Cheap
- Accessible
- Children and teenagers are the most frequent users

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Inhalants

- 18% of high school seniors - 30% of those reported use before age 10
- 20% of eighth graders

38

Solvents and inhalants

- Volatile intoxicants, anesthetics
- Low income communities particularly affected
- Affluent communities also affected
- Toluene can cause permanent neurological damage

39

Four major groups of solvents and inhalants

1. Volatile Solvents: Glue sniffing: lighter fluid, airplane glue, lacquer thinners, industrial solvents, ketones, propane and butane fuel, toluene, esters, and cleaning solutions

2. Aerosols: Aerosol propellants such as fluorocarbons. Spray paint, products containing chlorofluorocarbons, ketones, organic metal and n-hexane are particularly dangerous—they can cause cardiotoxicity, neuropathies, and hepatotoxicity

3. Anesthetic agents: Chloroform, methylchloride, nitrous oxide, trichloroethylene, and ethyl ether. Oil and grease dissolvers can contain some of this.

4. Butyl, Isobutyl nitrite, and amyl: Isobutyl nitrite used as a room deodorizer, Amyl nitrite used for angina. Called “poppers”

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Solvents and inhalants

- Alcohol increases the effect
- No dependence
- Onset is rapid and short duration
- Low doses cause euphoria, dizziness, slurred speech, ataxia, perceptual distortions, and impaired judgement
- High doses cause a generalized depressant effect

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Overdose of solvents and inhalants

- Photophobia, diplopia, sneezing, nausea, chest pain, diarrhea, eye irritation, respiratory depression
- Die of asphyxia

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Alcohol

- 10 % raised by alcoholic
- 43% have an alcoholic in life

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CNS effects of alcohol

- Alcohol is a CNS depressant
- Euphoria, decreased mechanical efficiency, and impaired thought processes
- Stimulatory effects from depression of inhibitory control mechanisms

44

Alcohol withdrawal syndrome

- Can happen with abrupt stop or big decrease in use that is sudden
- “Panic attack” – anxiety, palpitations, sweaty, nausea, shaking
- More severe – MAY be fatal and needs medical management
o Seizures
o Delirium tremens: auditory and visual hallucinations, disorientation

45

***How to withdrawal someone from AUD?***

- Benzos
- +/- fluids
- Nausea meds
- Thiamine, Magnesium, Niacin “banana bag”

46

Alcohol

- Alcohol disorders involve about 17-18 million individuals
- Alcohol abuse costs an estimated 184.6 billion dollars

47

Alcohol withdrawal syndrome

- Readjustment of the CNS to the neuroadaptation that occurs with prolonged intoxication
- Decreased GABA activity
- Increased Glutamate and NMDA activity

48

Alcohol and anxiety

- In an attempt to reduce anxiety, chronic alcohol use increases the brain chronic anxiety state
- When alcoholics cut down or quit – will feel that higher set point of anxiety

49

Alcohol withdrawal

6-96 hours after hrs after drink (or big reduction)
o Anxiety, tremulousness, HA, diaphoresis, palpitations, GI upset
o Tachycardia, hypertension, fever
o Generalized, tonic-clonic seizures, status epilepticus
o Auditory and visual hallucinations

***A rapid stopping or reduction in alcohol in someone who is chronic abuser can be fatal and needs to be medically managed***

50

Physical exam findings in abuse

- Ascites
- Caput Medusa (abdominal wall collaterals)
- Jaundice
- Malnutrition
- Splenomegaly
- Gynecomastia
- Digital clubbing
- Testicular atrophy
- Dupuytren’s contractures
- Tremors

51

Alcohol long term – Liver

- 50% Cirrhosis is caused by EtOH
- Healthy liver  Liver cirrhosis with EtOH

52

Alcohol and cancer

- The entire GI track (anything that is “touched” by elimination of EtOH) has an increased risk with heavy use

53

Alcohol and pancreatitis

- 50% of pancreatitis is EtOH related

54

Alcohol long term brain effects

- Causes brain atrophy – increases risk of brain bleed if fall
- Dementia – alcohol abuse big risk for early dementia
- Causes “scar tissue” between neurons

55

Alcohol treatment

Medical:
o Topiramate, ondansetron, naltrexone, acamprosate

Cognitive/behavioral:
o Controlled drinking
o Avoiding triggers
o Understanding WHY drink

Community based treatment:
o AA: well known

56

Study on alcoholism

- A 2007 study by the National Council on Alcoholism’s medical journal reported that people attending 12-step treatment programs had a 49.5% abstinence rate after a single year. Those who were in CBT programs were less successful, maintaining a 37% abstinence rate.
- Some report AA success at 5-10% - all in how you define success
- Where AA states you have no control, other programs try to teach how to have control

57

What we have learned about alcohol abuse

- A person’s use over time can be extremely variable
- Harm reduction strategies can work in some people

58

NIH

- Only 25% with AUD get help (including AA)
- Over time, 2/3 to ¾ of those with AUD will quit or reduce to moderate and stable

59

Study on alcoholism

- 100 alcohol dependent men – ½ got 3 week inpatient treatment and intense follow up versus 1 “brief advice” session followed by monthly telephone calls
- One year later – same results; two years later better results in the brief intervention

60

***Harm reduction model***

- ***Person continues to drink but effort to reduce the risk and harm – concentrates on riskiest first (like drunk driving)***
- GOAL ORIENTED

61

Moderation

- Many programs out there to get people to cut back
- Some people with AUD can do this and some people cannot

62

Things they don’t tell you in medical school

- People overcome addiction and use disorders (high school EtOH/Viet Nam and heroin) and MOST do it without treatment
- They quit or cut down to achieve normalcy
- Physicians can help
- Shame doesn’t work (neither personally or professionally)
- Developing coping mechanisms is huge

63

Children of alcoholics (or of hoarders or gamblers) may have these tendencies

- Feel that issues overshadowed your needs as a child
- Had to be caretaker earlier
- Independence
- Resilience
- Anxiety/anger/depression
- Sometimes choose partners with use disorders
- Duty to care for others
- Comfort of chaos

64

NOTE

f you have a use issue – this is the time to work on that as use disorders can crash a medical career (counseling, lots of websites, change who you spend time with)
- If you have someone important in your life with abuse disorder, get your own help