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M2 Psych > 10/18 Substance Abuse I - Williams > Flashcards

10/18 Substance Abuse I - Williams Flashcards

1
Q

alcohol/drug use disorders as chronic medical conditions

causative factors

A
  • genetic susceptibility
    • genetic risk is approx 50% (similar to other chronic conds)
  • chronic pathophysiologic/fx changes
  • risk factors influenced by choices
  • similar tx goals and strategies
  • similar clinical outcomes
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2
Q

substance use disorder

criteria

mild/moderate/severe

A

criteria can be lumped into 4 general buckets

2 or more in 12 months:

  1. phamarcological
    • ​​withdrawal
    • tolerance
  2. impaired control
    • desire or unsuccessful efforts to cut down/control use
    • great time spent obtaining/using
    • craving; strong urges to use
    • larger amounts consumed than intended
  3. risky use**​
    • use despite physical or psychological problems
    • use when it is hazardous
  4. social impairment​
    • use despite problems in relationships
    • failure to fulfill roles (work/school/home)
    • reduced occupational, recreational activity

mild → 2-3 sx

moderate → 4-5 sx

severe → 6+ sx

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3
Q

classification of substance use disorder

early/sustained remision,

A

early remission: 3-12mo abstinence

sustained remission: 12+mo abstinence

in controlled environment

on maintenance therapy (opioid)

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4
Q

substance induced disorders

A
  1. intoxication
  2. withdrawal
  3. substance induced mental disorder
  • delirium
  • dementia
  • amnesia
  • psychosis
  • mood disorder
  • anxiety
  • sexual dysfx
  • sleep disorder
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5
Q

clinician barriers

A
  • inadequate training/education
  • misperceptions/stereotyping
  • uncertain about what to do
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6
Q

at risk for drinking criteria

A

men

  • > 4 drinks/day or 14/wk

women

  • > 3 drinks/day or 7/wk

1/4 of all of these people will go on to have an alcohol use disorder

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7
Q

CAGE

A
  1. ever felt you should CUT DOWN on your drinking?
  2. every been ANNOYED by people criticizing your drinking?
  3. ever felt bad or GUILTY about your drinking?
  4. ever had a drink first thing in the morning to steady nerves or take care of a hangover? (EYE OPENER)

2 = positive test

1 = suspicious

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8
Q

assessment of SUD

A
  • clinical interview
  • amount, type, frequency
  • conseqs of use
    • legal
    • fxal
    • medical
    • psychological
    • social
  • physical exam and labs
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9
Q

alcohol use disorder

male/female

onset

risk factors

A

male: female = 3:1

onset between 16-30

risk factors:

  • tobacco use, depression/anxiety, antisocial personality disorder, some jobs, gambling, fam hx

women experience more medical consequences

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10
Q

fatty liver

A

experienced by almost all heavy drinkers

  • usually asymptomatic
  • reversible
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11
Q

alcoholic cirrhosis

4 fx of liver

how alcohol messes with these fxs

A

liver has many key fx; messing with them leads to issues

  1. portal HTN
  • hepatosplenomegaly
  • caput medusae
  • esophageal varices
  • hemorrhoids
  • affected: splenic, umbilical, esophageal, internal hemorrhoidal vv
  1. detoxifying fx
  • decr androgens → gynecomastia, testicular atrophy, decreased axillary/pubic hair, spider angioma or nevi
  • buildup of ammonia → asterixis, delirium, encephalopathy
  1. synthesizing fx
  • glucose
  • albumin → ascites, edema
  • coagulation factors (vitK-dep) → ecchymoses
  • bilirubin → jaundice, scleral icterus
  1. storage fx
  • thiamine (B1)
  • folate → macrocytic anemia/pallor
  • pyridoxine (B6) → pallor/anemia
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12
Q

what to look for in labs for alcohol use disorder

A

serum and urine toxicology/BAL

LFTs

  • GGT > 35; good marker for heavy drinking, normalizes after approx 5wk
  • AST, ALT; both abs value and ratio are important, but less sensitive than GGT
    • AST:ALT > 2 suggests AUD

MCV

triglycerides

platelets

carbohydrate deficient transferrin

  • abnormal form of transferrin
  • CDT > 20 g/L indicates heavy drinking
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13
Q

alcohol intoxication

A

1 or more of the following:

  • slurred speech
  • incoordination
  • unsteady gait
  • memory or attn impairment
  • stupor or coma
  • nystagmus
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14
Q

Wernicke encephalopathy

A

cause: acute thiamine (B1) deficiency due to dietary depletion

triad of sx:

  1. confusion
  2. ataxia
  3. ophtalmoplegia (eye muscle paralysis - usually lat rectus; nystagmus)
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15
Q

Korsakoff syndrome

A

cause: chronic thiamine (B1) depletion

NOT REVERSIBLE

sx:

  • impaired memory in alert, responsive pt
  • confabulation
  • retrograde and anterograde memory loss
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16
Q

Wernicke-Korsakoff syndrome

A

bilateral involvement of mammillary bodies → affects memory

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17
Q

alcohol tx

A
  1. intervention
  2. detox
  3. rehab

at risk drinkers?

  • help patients decrease drinking
  • minor intervention
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18
Q

substance withdrawal

diffs by substance type:

  • life threatening
  • severe discomfort
  • mild discomfort
  • no physio dep
A
  • life threatening
    • alcohol
    • sedative-hypnotic
  • severe discomfort
    • opiates
  • mild discomfort
    • cocaine
    • tobacco
    • amphetamine
    • cannabis
  • no physio dep
    • hallucinogens
19
Q

alcohol effects on neurotransmission

A

chronic alc use decreases GABAa receptor sensitivity

→→→ tolerance!

during withdrawal…

decreased GABAa receptor function (excitation more likely)

20
Q

signs of alcohol withdrawal

A
  • insomnia
  • flushing
  • tremor
  • nausea/vomiting
  • physical agitation, anxiety
  • sweating, rapid pulse
  • hyperreflexia
  • transient visual, tactile, auditory hallucinations or illusions
  • grand mal seizures (first 48hr)
21
Q

course of alcohol withdrawal

A

I : 12-48hr

  • peak severity at 36hr
  • 90% of AW seizure in this range
  • most cases self limited

II : 48-72hr

  • amplified StageI sx

III : 72-105hr

  • “delirium tremens”

IV (>7days)

  • protracted withdrawal
22
Q

predictors of AW severity

“complicated withdrawal”

A
  • severity of drinking/tolerance
  • older age
  • prior AW (“kindling”)
  • major medical/surgical problems
  • sedative/hypnotic use

complicated withdrawal: seizure, delirium, hallucinations, DTs

23
Q

delirium tremens

basics

sx

timecourse

A

MEDICAL EMERGENCY!

20% mortality if untreated

  • autonomic instability
  • perceptual disturbances
  • hyperactivity to lethargy

timecourse: preceded by seizure and lasts 3-7days

24
Q

tx of alcohol withdrawal

A

benzodiazepine taper (4-6days)

  • all types effective
  • incr GABAa receptor fx
  • decr seizures

carbemazapine, phenobarbital

thiamine and vitamin supplements

fluid/electrolytes (Mg and K)

check vitals frequently

25
Q

opiate intoxication/OD sx

A

“everything closes up”

  • miosis
  • respiratory depression (in OD)
  • hypotension
  • hypothermia
  • bradycardia
  • constipation
  • slurred speech
  • drowsiness/coma
26
Q

opiate antagonists

A

naloxone (Narcan)

  • IV/IM/SQ for opioid overdose (FDA approved)
    • this is the reason why adding naloxone to opiate (ex. oxy) deters pt from shooting up → precipitates opioid withdrawal

Naltrexone

  • oral
  • FDA approved for alc dependence, opiate dependence
27
Q

opiate withdrawal

A

“everything opens”

  • anxiety
  • yawning
  • diaphoresis
  • tearing, rhinorrhea
  • pupil dilation
  • piloerection/muscle twitching
  • nausea/vomiting
  • diarrhea, abd cramps
  • myalgias

NOT LIFE THREATENING

28
Q

opiate withdrawal tx

A

symptomatic relief

detox via:

  • clonidine (alpha adrenergic)
  • phenergan (antiemetic)
  • benzodiazepines
  • muscle relaxants

methadone (licensed facilities or for emergency tx)

buprenorphine (early withdrawal)

29
Q

opiate classification

receptor

types of interaction

A

mu receptor is the target of opiates

full agonists

  • morphine
  • oxycodone
  • methadone

partial agonist

  • buprenorphine

antagonists

  • naloxone
  • naltrexone
30
Q

buprenorphine

mech of action

what’s special about it?

types

A

mech: partial mu agonist with ceiling effect

  • can’t OD on it bc it doesn’t cause resp depression
  • lond duration of action
  • self tapering

office-based tx for opiate dependence

  1. suboxone: buprenorphine w/ naloxone
  • 4:1 → BUP:naloxone
  • sublingual bc naloxone not effective orally
  1. subutex: buprenorphine (without naloxone)
31
Q

can any doctor prescribe methadone?

A

for pain???

  • YES
  • less commonly used due to complex med interactions and long halflife
  • accumulation → sedation and resp depression

for addiction???

  • NO - can only be prescribed by licensed facility
  • reduces/eliminates use of non-prescribed opiates and use of cocaine
  • reduces risk of HIV and needle use
32
Q

hallucinogens

A

5HT2 receptor action

  • produce changes in thoughts, perceptions, mood
  • only minimal sedation
  • no change in memory or intellectual fx

hallucinations or illusions in a clear consciousness

ex. PCP, angel dust, ketamine, mescaline/peyote, marijuana, MDMA/MDA, etc

33
Q

hallucinogens

dependence, addiction

withdrawal

A

no abstinence syndrome

no detox needed

lethal OD is rare

instead…psychological dependence/compulsive use

34
Q

PCP

A

dissociative anesthetic (Schedule II)

long halflife: 24 hours

oral, IV, smoke, snort

  • psychosis resembling schizophrenia (agitates, paranoid, violent)
  • marked neuro signs: vertical nystagmus, ataxia
  • profound autonomic effects (v. dangerous)

mech: affects glutamate system via NMDA receptor

35
Q

marijuana

A

1 illicit drug in US

cannabis sativa

THC: delta-9-tetrahydrocannabinol is the major active chemical

WITHDRAWAL: psych symptoms

  • most occur within 2-3 days, but can last weeks
  • cravings
  • anxiety/depression
  • no libido
  • appetite incr or decr
  • boredom
  • shakes/tremor
  • insomnia/irritability
36
Q

dranabinol

A

synthetic oral cannabinoid

delta9 THC

  • anti-emetic for chemo
  • anorexia from AIDS

low abuse potential

37
Q

proposed medical uses for marijuana

A
  • anti-emetic
  • anti-spasticity
  • analgesic
  • appetite stimulation
  • anti-glaucoma
  • anticonvulsant
  • anti-asthmatic
38
Q

cocaine

onset/effect

intoxication sx

A

rapid onset (seconds) and short window (minutes)

intoxication sx:

  • hyperalertness
  • restlessness/pacing
  • talkative/pressured speech
  • aggression or elation
  • impulsivity
  • chest pain, other ischemia
39
Q

cocaine withdrawal (crash)

A
  • agitation/restless behavior
  • depressed mood
  • fatigue
  • generalized malaise
  • incr appetite
  • vivid and unpleasant dreams
  • slowing of activity
  • craving
40
Q

cocaine treatment

A
  • no cocaine-specific treatment
  • no detox needed
  • medications not proven effective
41
Q

D-methamphetamine

A

“meth”, “speed”, “chalk”

schedule II stimulant

  • oral, intranasal, injection, smoking

mechanism: releases high levels of DA

  • damages neuron cell endings (DA and 5HT)
  • reduced motor speed and impaired verbal lerning
  • chronic abusers: severe structural and fx changes in memory/emotion parts of brain
42
Q

psychological stimuland and sympathomimetic effect timecourse

A

8-24hr:

  • incr wakefulness, physical activity, resp, HR, BP, hyperthermia, irreg heartbeat, decr appetite
  • irritability, anx, insomnia, confusion, tremors, convulsions, CV collapse/death

long term:

  • paranoia, aggressiveness, extreme anorexia, mem loss, visual and auditory hallucinations, delusions, severe dental problems
43
Q

principles of strategic prescribing

A
  • avoid freq drug switching
  • follow evidence-based recs
  • be cautious about telephone prescriptions
  • start only one new drug at a time
  • don’t stretch indications
  • discontinue drugs that dont work
44
Q

what types of meds to avoid????

A
  • dependence liability
  • OD risk
  • cause seizures
  • cause sedation
  • cause liver tox

M2 Psych (24 decks)

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