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substance related disorders Flashcards

1
Q

substance abuse: dx

A
  • substance use causing impairment/distress for AT LEAST 12 MOs

1+ of:

  • W: failure to fulfill obligations at Work/school/home
  • I: Interpersonal/social probs
  • L: Legal problems
  • D: Dangerous use
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2
Q

substance dependence: dx

A
  • substance use causing impairment or distress

3+ of following WITHIN 12 MO PERIOD

  • tolerance
  • w/drawal
  • using more than originally intended
  • persistent desire/unsuccessful efforts to cut down
  • significant time spent getting/using/recovering from substance
  • decreased social/occupational/recreational activities
  • continued use despite physical/physiological problem
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3
Q

substance abuse/dependence: epidem

A
  • lifetime prev: 17%
  • men > women
  • alcohol and nicotine most common
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4
Q

alcohol use: physiology

A
  • GABA and 5HT activation
  • glu and Ca-channels inactivated
  • overall: CNS depressant
  • alcohol –> acetaldehyde by alcohol dehydrogenase
  • acetaldehyde –> acetic acid by aldehyde dehydrogenase (lacking in Asians)
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5
Q

alcohol use: epidem

A
  • dependence: 3-5% of women and 10% of men

- many more meet criteria for abuse in their lifetime

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6
Q

alcohol intoxication: clinical presentation

A
  • decreased fine motor control
  • impaired judgment and coordination
  • ataxic gait and poor balance
  • lethargy, difficulty sitting upright, memory probs
  • coma in novice drinker
  • respiratory depression, death possible at highest BAL
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7
Q

alcohol intoxication: tx

A
  • monitor: ABCs, glucose, electrolytes, acid-base status
  • thiamine (Wernicke’s) and folate
  • naloxone if co-ingested opioids
  • CT to rule out brain injury
  • may need resp support

DO NOT do GI evacuation unless significant ingestion w/in 30-60 min

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8
Q

alcohol withdrawal: clinical

A
  • insomnia, anxiety, hand tremor, irritability, anorexia, nausea, vomiting, autonomic hyperactivity, psychomotor agitation, fever, SZ, hallucinations, delirium
  • earliest sx: 6-24 hrs
  • sz: 6-48 hrs, peak at 13-24 hrs
  • 1/3 of people with sz develop DTs
  • tx of sz: BZOs
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9
Q

DTs

A
  • usually 48-72 hrs after last drink
  • 15-25% mortality rate if untreated
  • predisposition if physically ill
  • men&raquo_space;> women
  • visual hallucinations, gross tremor, fluctuating levels of psychomotor activity
  • tx: BZOs
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10
Q

alcohol withdrawal: tx

A
  • BZOs for sedation/agitation, then slow taper
  • antipsychotics and restraints for severe agitation
  • thiamine, folic acid, multivitamin = banana bag
  • check for hepatic failure
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11
Q

alcohol dependence: tx

A
  • Antabuse = disulfiram: blocks aldehyde dehydrogenase –> flushing, HA, N/V, palpitations, SOB
  • naltrexone: opioid rcptr blocker, best benefit in family hx of alcoholism, precipitates w/drawal in opioid dependents
  • acamprosate: similar to GABA, inhibits glu system; start post detox, can be used in patients with liver dx (NOT with renal dz)
  • topiramate: anticonvulsant, potentiates GABA and inhibits glu, decreases cravings
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12
Q

alcohol use: lab values

A
  • AST:ALT >= 2:1
  • elevated GGT
  • increased MCV
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13
Q

Wernicke’s encephalopathy

A
  • due to thiamine deficiency
  • can be reversed with thiamine therapy
  • broad-based ataxia, confusion, ocular: nystagmus, gaze palsies
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14
Q

Korsakoff syndrome

A
  • from untreated Wernicke’s
  • chronic amnestic syndrome
  • 80% NONreversible
  • impaired recent memory, anterograde amnesia, compensatory confabulation
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15
Q

cocaine use: physiology

A
  • blocks dopa reuptake

- dopa –> reward

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16
Q

cocaine intox: clinical

A
  • euphoria, increased self-esteem, change in BP, tachy/bradycardia, nausea, dilated pupils, weight loss, chills, sweating
  • resp depression, sz, arrhythmias, paranoia, hallucinations (TACTILE)
  • vasoconstriction may –> MI or stroke
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17
Q

cocaine intox: tx

A
  • mild: reassurance, BZOs
  • severe agitation/psychosis: haldol/antipsychotic
  • symptomatic support
  • aggressive tx of T > 102
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18
Q

cocaine dependence: Tx

A
  • off-label: disulfiram, aripiprazole

- psychological interventions: contingency management, group tx, etc

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19
Q

cocaine withdrawal: clinical

A
  • crash: malaise, fatigue, hypersomnolence, depression, hunger, constricted pupils, vivid dreams; occasional suicidality
  • mild-moderate use: sx resolve w/in 18 hrs
  • heavy use: may last for weeks
  • tx: supportive unless psychotic sx require hospitalization
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20
Q

classic amphetamine: physiology

A
  • block reuptake and increase release of DA and NE
  • e.g. dextroamphetamine, methylphenidate, methamphetamine
  • used medically in tx of: narcolepsy, ADHD, depressive dos
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21
Q

substituted amphetamine: physiology

A
  • release DA, NE, and 5HT
  • e.g. MDMA, MDEA
  • stimulant and hallucinogenic properties
  • potential for serotonin syndrome
22
Q

amphetamine use: sx

A
  • dilated pupils, increased libido, persipiration, resp depression, chest pain
  • chronic use: acne and accelerated tooth decay
  • heavy use: amphetamine psychosis, mimics SCZ
  • OD: hyperthermia, dehydration, rhabdo
  • w/d: prolonged depression
23
Q

ketamine

A
  • tachcardia
  • tachypnea
  • hallucinations
  • amnesia
24
Q

PCP: pathophys

A
  • antagonizes NMDA glu rcptrs, activates DA
  • stimulant or depressant effects depending on dose
  • wet = on cigarette, joint = on marijuana
  • ketamine is similar but less potent
25
Q

PCP: intoxication

A
  • R: rage
  • E: erythema
  • D: dilated pupils
  • D: delusions (tactile and visual hallucinations)
  • A: amnesia
  • N: nystagmus (rotatory = pathognomonic)
  • E: excitation
  • S: skin dryness
26
Q

PCP: OD

A
  • sz
  • coma
  • death
27
Q

PCP: tx

A
  • monitor vitals, temp, electrolytes, minimize sensory stim
  • BZOs for agitation, anxiety, muscle spasms, sz
  • antipsychotics as needed
28
Q

PCP: w/d

A
  • no syndrome

- “flashbacks” due to release from lipid stores

29
Q

BZOs: physiology

A
  • potentiate GABA

- increase frequency of Cl-channel opening

30
Q

barbiturates: physiology

A
  • potentiate GABA
  • increase duration of Cl-channel opening
  • high dose: act as direct GABA agonists
31
Q

sedative intoxication: clinical

A
  • drowsiness, confusion, hypoT, slurred speech, ataxia, modd lability, nystagmus, respiratory depression
  • synergistic sx with EtOH and opiates
  • long term use –> dependence, depressive sx
32
Q

sedative intoxication: tx

A
  • ABC, vitals
  • charcoal, gastric lavage (if ingested in last 4-6 hrs)
  • barbiturates: alkalinize urine with NaHCO3
  • BZOs: flumazenil (may precipitate sz)
33
Q

sedative withdrawal

A
  • abrupt abstinence after chornic use: deadly
  • especially for barbiturates
  • seizures!
  • tx: BZO taper
  • possible carbamazepine or VPA taper for sz prevention
34
Q

opioid physiology

A
  • stimulate opiate rcptrs (mu, kappa, delta) –> sedation, analgesia, dependence
  • effects on DA system –> reward, addiction
35
Q

opioid intoxication: clinical

A
  • drwosiness, N/V, contispation, slurred speech, miosis, sz, resp depression
  • DEMEROL (meperidine) DILATES PUPILS
  • meperidine and MAOis –> serotonin syndrome
36
Q

opioid intox: tx

A
  • ABCs
  • naloxone/naltrexone (may cause withdrawal)
  • ventilatory support if needed
37
Q

opioid withdrawal

A
  • unpleasant, NOT lethal
  • anxiety, insomnia, anorexia, fever, dysphoria, insomnia, lacrimation, rhinorrhea, yawning, weakness, sweating, piloerection, N/V, cramps, etc etc
  • tx: moderate sx –> clonidine, NSAIDs, etc
  • tx: severe sx –> buprenorphine or methadone detox
38
Q

methadone

A
  • long acting opioid antagonist
  • gold standard for pregnant women
  • can cause QTc prolongation
39
Q

buprenorphine

A
  • partial opioid antagonist
  • sublingual, plateau of effects
  • suboxone: buprenorphine + naloxone: limits diversion
40
Q

naltrexone

A
  • competitive opioid antagonist
  • precipitates withdrawal
  • problem: COMPLIANCE
41
Q

hallucinogens: physiology

A
  • LSD: 5HT
  • no physical dependence or w/d
  • rare psychological dependence
42
Q

hallucinogenic intoxigation

A
  • perceptual changes
  • labile affect, dilated pupils, tachycardia, HTN, hyperthermia, tremors, sweating, palpitations
  • lasts from 6 hrs to several days
  • tx: monitor and reassurance
  • tx as necessary for agitated psychosis
43
Q

marijuana: physiology

A
  • cannabinoid rcptrs in brain inhibit adenylate cyclase

- decreases nausea, increases appetite; decreases intraocular P, muscle spasms, tremor

44
Q

marijuana: intoxication

A
  • CONJUNCTIVAL INJECTION
  • euphoria, anxiety, impaired coordination, anxiety, increased appetite
  • may induce psychosis
  • 5%: marijuana dependence
  • chronic use: resp problems, immue suppression
  • tx: supportive, psychosocial
45
Q

inhalants: intoxication

A
  • perceptual disturbances, psychosis, lethargy, dizziness, N/V, HA, nystagmus, tremor, etc etc
  • acute intoxication lasts minutes, stupor may last hours
  • OD may be lethal 2/2 resp depression, arrhythmias
  • long-term use: permanent CNS or PNS damage, or to liver/kidney/heart/muscle
46
Q

caffeine: physiology

A
  • adenosine antagonist

- increased cAMP and DA stimulation

47
Q

caffeine overdose

A
  • 250mg (2-3 cups): anxiety, insomnia, mm twitching, rambling speech, diuresis, GI disturbance
  • > 1g: tinnitus, severe agitation, visual light flashes, cardiac arrhythmias
  • > 10 g: death possible 2/2 sz or resp failure
48
Q

caffeine withdrawal

A
  • 50-75% of caffeine users

- HA, fatigue, irritability, N/V, drowsiness, anxiety, mm pain, mild depression

49
Q

nicotine: physiology

A
  • nicotinic rcptrs in symp and parasymp NS
  • also affects DA system –> addictive
  • tolerance and physical dependence common
50
Q

nicotine: tx

A
  • varenicline: nAChR partial agonist, prevents w/d sx
  • bupropion: partial agonist at nAChR and inhibits DA reuptake
  • nicotine replacement therapy
  • behavioral counseling

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