Addiction and Adult ADHD Flashcards
(87 cards)
1
Q
The key neurotransmitter involved in reward pathway is __
A
dopamine
2
Q
Significant amount of dopamine is released in the prefrontal cortex (via the ___ pathway)
A
mesocortical
3
Q
The prefrontal cortex is involved in __, __, and __
Brain learns value/worth of certain behaviors -> impacts future planning, decision-making
A
- planning,
- organization,
- decision-making
4
Q
The mesocorticolimibic projection is made of __ + ___
A
mesolimibic pathway
mesocortical pathway
5
Q
What are natural rewards
A
- Eating, drinking, nurturing infants, sex
- These are all activities that keep humans alive individually and as a species -> evolutionary benefit to having these trigger increased dopamine levels
6
Q
Describe drugs effects on the reward pathway
A
-Drugs are highly rewarding via increased dopamine levels/longer duration of dopamine in the brain!
7
Q
- Drugs that increase DA release
- DA reuptake inhibitors/DA present in synapse longer Drugs
A
- cocaine, methamphetamine, heroin
- Cocaine, amphetamines
8
Q
Describe Positive reinforcement
A
Positive reinforcement for these behaviors via increased dopamine release -> people keep engaging in these behaviors (stimuli -> dopamine -> repeat)
9
Q
Describe positive reinforcement and the concept of “what fires together, wires together”
A
- Behavior produces + reward–> Dopamine
- the + reward makes the behavior more likely to occur
- “Fires together, wires together”– brain forms fast connections btwn things that happen together so we can predict what may happen based on connection we have made in similar situations previously
10
Q
Give an example of + reinforcement and the concept “what fires together, wires together”
A
Example of beginning to use heroin in a friend’s car in a parking lot in Target at a certain time
- Heroin -> increased dopamine -> rewarding -> continue using heroin
- Then start to associate heroin to the situation and people that you usually are with when using heroin
- Pretty soon whenever they see the same car as their friend’s car -> have a craving for heroin
- Then becomes generalized to every time they pass a Target -> have a craving for heroin
- Can also then having cravings every time they see the friend they usually shoot up with
*Craving are not just about seeing/smelling heroin -> many aspects of their general life can trigger cravings
11
Q
How do drugs encourage behavior via negative reinforcement?
A
- Neg. reinforcement encourages behavior- allows person to escape negative experiences
- Physical symptoms (withdrawal sx – n/v/d, body aches, dysphoria, feeling of doom/darkness)
- Emotions (guilt, shame, depression, anxiety)
- Trauma (either ongoing or PTSD, “self-medicating”) - Punishment discourages behavior
- Punishment= behavior then neg. consequence
- Punishment can lose potency over time
12
Q
Reasons for initial drug use
A
- Positive reinforcement via increased dopamine levels
2. Experience euphoria -> want to continue using drug to experience same sensation
13
Q
Reasons for persistent drug use
A
- Negative reinforcement (withdrawal sx) encourages drug use
- Quickly move from euphoric phase of drug use to experiencing withdrawal sx
- Must use drug to prevent withdrawal or even to feel “normal”
14
Q
Perspective of addiction as an __ response to environment
A
adaptive
-Trauma/loss, systemic/generational oppression, racism, mental anguish (depression, anxiety), social insecurity/phobia, isolation, boredom
15
Q
What is the Rat Park Study
A
- 2 rats in different environments
- 2 water bottles in each environment: 1 with water and 1 with cocaine (a sweetener was used so water tasted the same)
- 1 rat was placed in a plain cage
- Very quickly began to use the cocaine laced water bottle almost exclusively - 1 rat was placed “rat park”- had good food, lots of stimulation (puzzles, wheel)
- Tried both water bottles, but then almost exclusively chose to use the plain water bottle
* **Substance abuse may have a great deal of dependence on our external environment (being bored, lonely really matters on continuing to use!)
16
Q
What are the 5 C’s for substance use disorder
A
- Craving
- Compulsive use
- Continued use despite harm (consequences)
- Chronicity
- Control, loss of
17
Q
What are Cravings?
A
- Cravings are often described as this overwhelming idea or thought in my mind to engage in an activity
- Must engage in activity to get on with their day
- Bothersome type of experience
18
Q
- Cannot control behavior of using more and more of substance, even if do not want to
ex. Have 10 oxycodone to last 3 days, but use them all in 3 hours
A
Compulsive use
19
Q
- Lose job, family, friends, health (develop endocarditis, hepatitis)
- Means they cannot stop using substance without support/rehab
A
Continued use despite harm
20
Q
Describe chronic vs acute substance use
A
Every other day for 6 months (chronic) vs. use for 3 days every 6 months (acute)
21
Q
Other features of substance abuse disorder
A
- Inability to fulfill work or social obligations
- Use in dangerous situations
- Legal problems
- Interpersonal problems
- Mild (1-3), Moderate (4-5), Severe (6+)
22
Q
needing to increasing doses of a substance to achieve the desired effect
A
Tolerance
*Physiologic effect/adaptation to a substance
23
Q
___ is not in physical consciousness or control
A
Tolerance, dependence
24
Q
physiologic adaptation to presence of substance, such that the substance is now required to maintain homeostasis
A
Dependence
25
substance specific set of symptoms related to absence of substance of dependence
Withdrawal
*Occurs when dependence has developed, and then person abruptly stops using substance
26
Body has adapted to functioning to a certain level of substance -> without substance -> develop withdrawal symptoms until
body is able to achieve homeostasis again in the absence of the substance
27
__ does not equal addiction
Withdrawal
28
What meds tx opiate abuse
1. Methadone (full opioid agonist) dosed 1-2x day (long acting)
2. Buprenorophine (1-3x/day or every other day)
3. Suboxone (buprenorphine + naloxone)
4. Naltrexone
29
Describe where/how Methadone is prescribed
- Regulated by federal and state authorities
- can only be provided for the treatment of addiction from one of these specially designated clinics (cannot be prescribed as an outpatient)
- If being used to tx addiction, must be prescribed at a specialty clinic= Liquid form of methadone used at specialty clinics
- Can only be prescribed outpatient for pain management= Tablet form of methadone used for outpatient pain management
30
Partial opioid agonist (high affinity for opioid receptors -> binds receptors more tightly than heroin)
Buprenorphine
31
Describe how suboxone/buprenorphine can be prescribed
Outpatient prescription
- Filled at pharmacy
- Patient can take medication at home
- Prescribed by provider (MD/DO, NP, or PA) who completes training
July 2016 CARE act -> NPs and PAs can now prescribe Suboxone***
- Requires 24 hrs of training, then applying to DEA fro waiver
- Can treat 30 patients in first year, then up to 100 pts/year
32
Opioid antagonist (disrupts reward pathway) Approved for treatment of alcohol and/or opiate use
Naltrexone
*Not Antabuse (disulfiram) – will not have a violent reaction to alcohol, but if drink while taking medication, might not like it as much
33
Describe how Naltrexone is prescribed
- No special training or license required (but special pharmacy support required for Vivitrol)
- Daily oral tablet (Depade) or monthly injection (Vivitrol)
34
Length of medication treatment for addiction
- Suggest a minimum of 12 months to allow for both sufficient time for neurobiochemistry and lifestyle changes
- No upper limit to duration of treatment (Can stay on medications as long as they are needed)
*Some people are highly motivated to get off maintenance therapy
35
What are the public health consequences related to excessive alcohol consumption?
1. Nondependent unhealthy alcohol use (the top 25% of the alcohol pyramid) spread across the whole population accounts for the majority of harm associated with alcohol
2. Drunk driving, health consequences leading to increased health care cost, etc.
* More than all other substance use disorders
3. The top 4% does not account for enough people to make a significant public health impact; also they are not in public as much -> less harm to public (drunk/passed out at home)
36
Understand the difference between types of alcohol consumers in the US (the pyramid), approximately what percentage of people fall into each category and the type of treatment a provider should offer
1. Abstainers or low-risk drinkers = 70%
* Providers give positive reinforcement to support this group
2. Risky drinkers = 25%
* Providers can give brief intervention to support this group
3. Alcohol dependent = 4%
* Providers can best support this group by referring to treatment center
37
the lower risk drink limits for women, men and adults over 65
Women: occasion 3, Weekly 7
Men: Occasion 4, weekly 14
Over 65: occasion 3, weekly 7
* less is better
* *Do not get to bank drinks
* drink limits can be very different from cultural norms (binge drinking)
38
the quantity of alcohol that qualifies as “a drink”
12oz Beer
5oz Wine
1.5oz liquor
39
What are unhealthy alcohol use behaviors
1. binge drinking
2. high weekly use
3. ANY during pregnancy-- recommendations stand there is NO safe alcohol intake level (FASD can have effects seen later, memory, attention, behavior)
4. Any alcohol under 21
40
Describe acute health effects of alcohol
| *Too much in a single day--> intoxication
1. decrease coordination
2. decrease cognitive fxn
3. increase risk taking
4. burns
5. falls
6. drowning
7. motor vehicle crash
8. pedestrian injury
9. LOC/ alcohol poisoning
10. assaults/intimate partner violence/child abuse
11. property crimes
12. suicide/homicide
13. risky sex
14. FASD and med interactions (chronic effect too)
41
Describe chronic health effects of alcohol
| *Too much in a week--> repeated toxic exposure
1. cell and tissue damage
2. CA
3. cirrhosis/liver failure
4. pancreatits
5. gastritis
6. addiction
7. hypertension
8. CV dz
9. neurologic damage
10. wt gain
11. FASD and med interactions (acute effect too)
42
What are Potential benefits of SBIRT (Screening and Brief Intervention and Referral to Treatment)
1. Early substance abuse intervention= improved outcomes and substance use disorder ARE preventable
2. Alcohol screening and brief counseling can reduce alcohol consumption by 25% in those who drink too much
3. Recent research found that SBI for drug use did not reduce days of use for marijuana, illicit or prescription drug misuse-
Does not mean that providers should not do this for patient with drug abuse, but that it may not have the same dramatic impact as with alcohol
4. Adolescents may require more intensive intervention, or multiple interventions to effectively address substance use
43
What is SBIRT
(Screening, Brief Intervention and Referral to Treatment)
- S: Screen using validated questions to identify alcohol, tobacco and drug use
- BI: A brief conversation to provide feedback and enhance motivation to cut back or stop unhealthy substance use
- USPSTF Grade B recommendation for alcohol but I statement (insufficient evidence) for drugs and in adolescents
- AAP: recommends SBI for alcohol, drugs, and tobacco
44
ask the single question alcohol screening questions to adults over 18+ and recognize a “positive” response
1. How many times in the past year have had X or more drinks in one day?
* Where X = 5 for men and X = 4 for women
**Positive score = 1 or more times
2. When was the last time you had X or more drinks in one day?
* Where X = 5 for men and X = 4 for women
* *Positive score = in the past 3 months
* *Any alcohol use by pregnant women or age < 21 is considered a positive score
45
What do you do if someones screens positive for the single question alcohol screening question to adults over 18+
1. Interpret screening results and share with the person
2. Document results in patient record -- Ask If it is ok to document in a patient’s record your concerns
3. Can get a little sensitive if have open notes, but as long as had a conversation with them about this then it’s ok because this is not new information
4. Provide brief intervention
46
ask the single question marijuana screening questions and recognize a “positive” response
How many times have you used marijuana in the past year?
* Positive score = 1 or more times
* *Any marijuana use warrants further assessment to determine how much, reasons for using, and discussion about harm reduction
47
ask the single question tobacco screening questions and recognize a “positive” response
Do you currently smoke or use nay form of tobacco/electronic nicotine?
Positive score = Yes
48
Understand the purpose of the Brief Intervention
Short conversation to provide feedback and enhance motivation to cut back or stop unhealthy substance use
* Incorporates the spirit and principles of MI:
1. Empathetic listening
2. Collaborative
3. Respect for autonomy
a. If patient is guarded and not ready to have this discussion -> it is ok just to try again another time
b. Worse for provider to push their agenda onto a patient when they are not ready to hear that information
4. Elicit intrinsic motivation for change
5. Explore and resolve ambivalence about change
6. Reinforce commitment and confidence about change
49
Describe the process of change
* Not a linear process -> usually some back and forth, circling back -> may fall back into their old ways
- All part of normal process of change
- Do not feel that you have “failed” if patient falls back into their old habits
Pre-Contemplation--> contemplation--> preparation--> action--> maintenance--> relapse--> precontemplation
50
be able to perform the 4 steps of brief intervention outlined by Dr. Klie (be aware that your interaction will be based on the person’s Stage of Change)
1. Raise the subject--"Would you mind taking a few minutes to talk with me about your screening results?”
2. Provide feedback
3. Enhance motivation
4. Negotiate and advise
51
Describe Step 2 of the 4 steps of brief intervention
Step 2: Provide feedback
1. Review reported substance use
2. Compare reported alcohol use to moderate limit for adults
3. Provide feedback on health or other potential effects of use
4. Link substance use to purpose of your visit with the patient
5. Offer educational resources
6. **Don’t give too much information!
7. **Always elicit the person’s response to the feedback you provided
52
Describe Step 3 of the 4 steps of brief intervention
Step 3: Enhance motivation
1. Explore the pros and cons of drinking-- "What are some thinks you like and dont like about drinking"
2. Assess Readiness-- scale 0-10 how ready are you to cut back- why that number?
3. Assess confidence- scale 0-10 how ready are you to that you can make that change- why that number?
4. A few addtional
53
How should you react if a patient does not want to engage in a brief intervention/step 3 enhance motivation conversation
1. “I would not be a good health care provider if I did not bring this up and share with you my concerns, but I can tell you do not want to discuss this today. I am concerned enough that I won’t just let this go on forever, but we don’t have to talk about this today.”
2. If heroin abuse – give clean syringe exchange information, and a naloxone prescription at minimum
3. Very clearly document that patient did not want to engage in this discussion, and was given information about harm reduction strategies
54
Describe Step 4 of the 4 steps of brief intervention
Step 4: Negotiate and advise
1. Elicit a response: “What are some your thoughts about our discussion?”
2. Negotiate a goal: “What are some steps you could take to make a change?”
3. Assist in developing a plan:
a. What will be challenging about this for you?
b. How could you approach these challenges?
4. Summarize: “It sounds like you plan and next steps are _____.”
5. Thank them: “I appreciate that you were willing to about this with me.”
55
Who needs Referral to Treatment (RT) to tx unhealthy alcohol use
1. A person with a pattern of binge drinking
2. A person who has already experienced serious consequences of alcohol or drug use
3. A person with possible substance use disorder
Continuum of Care
1. Support groups, educational classes (DUI, DWAI)
2. AA, NA, CA, SMART recovery, Celebrate Recovery, Women for Sobriety, etc.
3. Medical Detox
4. Intensive Outpatient
5. Residential Treatment
6. Extended Care
7. Sober Living
8. Therapeutic Communities
56
What are medication options for primary care for alcohol?
1. Naltrexone (oral tabs and inject)
2. Acamprostate (Campral)
3. Gabapentin
4. Topiramate
5. Anatabuse (disulfiram)
57
Describe what Naltrexone is and how it works
1. Opioid antagonist
(EtOH acts on may different receptors in the brain, including the reward pathway)
* **Decreasing cravings for alcohol; do not get sick if drink alcohol while taking medication, but do not enjoy drinking alcohol as much
2. Helps to unhook pattern of behavior of drinking and then reward of enjoying how much it makes you feel
3. *Changes self talk – “I don’t like alcohol anymore”
4. No special training or license required (but special pharmacy support required for Vivitrol)
Daily oral tablet (Depade) or monthly injection (Vivitrol)
58
- Good for post-acute withdrawal symptoms (PAWS) of alcohol
| - Helps to rebalance the GABA-glutamate imbalance that brain has during PAWS
Gabapentin
59
- Will become very ill if drink alcohol while taking medication; can have a disulfiram reaction to even light amounts of alcohol (hand sanitizer, soy sauce, cologne)
- Does not treat or address cravings
- Does not have the best evidence supporting efficacy
- Many times have mandated use in correctional facilities
Anatabuse (disulfiram)
60
What are medication options for primary care for tobacco?
1. Varenicline (Chantix) – nicotine receptor blocker
2. Buproprion (Zyban) – NDRI
3. Nicotine Replacement Therapy
61
potential risks of NOT treating ADHD in kids and adolescents
1. Poor academic performance (labeled as “dumb”)
2. Lack of friendship/peers
3. Increased risky behavior (7x increased risk of substance abuse in adolescents)
4. Poor self-esteem
5. Inability to achieve full “potential”
62
describe how ADHD presents in kids
Boys = tend to have more behaviors issues, hyperactivity component
Girls = tend to be more distracted, looking out the window, often get misdiagnosed, labeled as “day dreamer”, “unmotivated”
*More likely to DX in boys than girls
63
Describe common ADHD presentation in adults
1. Child was recently diagnosed with ADHD and he/she is “just like me!”
2. Increase in intellectual demands (school – just started graduate school, home- new baby/children, work – promotion) and coping mechanisms no longer work
3. Comments by friends/family
History consistent with ADHD
1. Not achieving potential in school, career etc.-- Not just about grades/academic performance – “Did you ever have trouble taking tests, getting home work done?”
2. Inconsistency/impulsivity in various areas (relationships, work, school)-- Many different jobs, schools, homes, living areas, marriages, etc.
3. Not finishing or accomplishing goals --Start many different things, but do not follow through w/completing goals
- How come they never finished their graduate degree? Why do they keep jumping between jobs?
64
What is the DSM 5 of "Inattention"
6+ symptoms (5+ if over 17 or older) for at least 6 mos that negatively affects social and academic/occupational activities (present in >1 setting)
1. Does not pay attention to details/makes careless errors
2. Difficulty staying focused in tasks or play
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions and finishing schoolwork, work tasks etc. (starts but loses interest)
5. Shows difficulty with organizing materials and time-management (messy, misses deadlines)
6. Avoids or dislikes activities that require sustained attention (homework, preparing reports etc.)
7. Often loses things necessary for activities (keys, pencils)
8. Easily distracted by extraneous stimuli or thoughts
9. Often forgetful in daily activities (chores, errands, returning phone calls)
65
What is the DSM 5 of "Hyperactivtiy/Impuslivity”
6+ symptoms (5+ if over 17 or older) for at least 6 mos that negatively affects social and academic/occupational activities (present in >1 setting)
1. Fidgets with or taps hands/feet, squirms in seat
2. Leaves seat/workplace when not appropriate
3. Runs/climbs when not appropriate (or feels restless)
4. Unable to play or engage in leisure activities quietly
5. Often “on the go”, “like a motor”
6. Talks excessively
7. Blurts out answers, interrupts in conversations
8. Difficulty waiting turn
9. Interrupts or intrudes on others (conversations, games, activities etc.)
**What people typically think of when thinking of ADHD; inattentive component is less obvious
66
What are other diagnostic criteria for ADD
1. Several symptoms must be present before age 12
2. Symptoms present in 2+ settings
3. Clear evidence that symptoms interfere with quality of life
4. Not explained better by other disorder
67
ADD vs ADHD
ADD = attention deficit disorder; has inattention component only!
ADHD = attention deficit hyperactivity disorder; has both inattention and hyperactivity/impulsivity components
- Adults – many times will not see hyperactivity/impulsivity component pieces as much because they have learned to control this over time
- Children – many times will see more of ADHD (hyperactivity) presentation
68
Understand the concept of “Attention Inconsistency” and how it differs from “Attention Deficit
- Attention Deficit can be misleading – interpret this to mean people are not paying attention at all
- Better to think of this as having “attention inconsistency”
- Ability to focus for long periods (“hyperfocus”) on areas of interest
- Often highly successful in those areas of interest (Michael Phelps, Justin Timberlake, Einstein -> people who were able to “channel” their ADHD)
- Difficulty focusing when required or when uninterested
- May present as having an academic history of exceeding in areas of interest (science) and struggling in other areas (English, history, etc.)
69
What are ADHD stimulate meds and how do they work?
1. Adderall (1st line in adults, 2nd in peds)
2. Ritalin (2nd line in adults, 1st in peds)
3. Concerta (long acting ritalin)
4. Dexedrine
Stimulate the deficient area of the brain (dorsolateral prefrontal cortex) to increase dopamine
*Can take stimulants as needed – do not have to take everyday like with antidepressants or have to taper doses like with anti-depressants
70
Side effects of stimulants
1. Blood pressure, heart rate can increase (monitor)
2. Caution with cardiovascular conditions
- Adults - check with their cardiologist prior to starting medications
- Pediatrics – have an EKG completed prior to starting medications
3. Nausea (take with food), decreased appetite
4. Headache (often at beginning/end of dose)
5. Increased risk for hypomania in BPD
6. Increased anxiety
7. Insomnia
8. Risk for tolerance
71
Benefits of Strattera (atomoxetine)
-Norepinephrine Reuptake Inhibitor
1. Once daily medication (coverage of symptoms 24/7)
2. No potential for tolerance/addiction
3. Can also help with depression
72
SE/Cons of Strattera
* SE similar to SNRI's
1. GI upset
2. insomnia
3. HA
4. Not as effective as stimulants, but can be good as adjunct
73
describe how Intuniv (guanfacine) works for ADHD
Alpha-adrenergic agonist
1. Blocks sympathetic nervous system impulses (thereby decreasing peripheral vascular resistance and pulse rate)
2. Used as an adjunct to treating ADHD
3. 1mg in AM or before bedime
74
Intuniv (guanfacine) is often most effective for ___ and ___ associated with ADHD
physical symptoms (agitation, impulsivity) AND emotional (low self-worth
*Biggest barrier to use in adults in cost (not covered by insurance)
75
Types of drugs used for ADHD
1. Stimulants
2. Straterra (NRI)
3. Intuniv (guanfacine) a-agonist
4. Antidepressants (SNRI or NDRI)
76
Describe what Antidepressants can be used to tx ADHD
1. Wellbutrin – NDRI
- Increases levels of NE and DA
- Can help with motivation, concentration
- Also helpful if patient has concurrent depression
2. SNRI’s (Effexor XR, Pristiq, Cymbalta, Remeron):
- Increases levels of NE
- Can help with motivation, concentration
- Also helpful if patient has concurrent depression
77
- Used to treat excessive sleepiness
- Often helpful with increasing energy level/concentration
- Cost prohibitive – very expensive and not covered by insurance
Provigil/Nuvigil (modafanil)
78
What are some ADHD "life skills"
1. Medications treat underlying imbalance, but do NOT address unlearned habits and skills
2. Adults with ADHD often have not learned necessary skills related to organization, time management, building relationships etc.
3. Books, therapy, life coaching etc. can be very helpful to learn these skills
79
Understand the differences between the kinds of Adderall and when/why one type might be used versus another
1. Adderall IR (immediate release)---> start w/ this (shortest half-life)
* Can split
2. Adderall XR--> if good response to IR can do a trail of XR and/or Vyvanse
* Can't split
3. Vyvanse- longest acting adderall
* Capsules so can mix in water
80
What adderall has the highest SE..... and what are they?
Adderall IR
1. HA
2. Jittery/anxiety
3. decreased appetite
4. insomnia
81
describe the metabolism of Adderall IR
Huge variance in metabolism, but lasts approximately 4-6 hours
82
Manage expectations of Adderall IR (activating effect of stimulants often short-lived)
1. Many times when starting the medication the patient will have lots of energy and decreased appetite
2. These effects tend to go away as continue using the medication
3. Can lead to the addictive quality of Adderall -> patients want to continue having increased energy and decreased appetite
4. This is why it is better to help patient focus on their core bothersome characteristics and note whether the medication improves these symptoms
83
Benefits of Vyvanse
1. long acting so only need 1 dose
2. fewer dietary interactions (vi. C)
3. lower rate of SE (smoother)
84
Be able to come up with an initial pharmacologic treatment plan for an ADHD patient, including medication choice and anticipatory guidance
1. Treat mood disorders first then see what symptoms have not resolved.
2. Be aware that medication has been shown to be far SUPERIOR to lifestyle changes**
3. -1st line = Adderall, 2nd line = Ritalin
- Adjunct = Strattera, antidepressant, or Intuniv (often cost prohibitive).
4. Identify and write down 3-4 “core” symptoms to follow at subsequent appointments (ex: forgetfulness, interrupting, procrastination)
85
Be able to counsel a patient as to why his daily stimulant dose should be limited (ex: 40 mg a day total of Adderall)
1. Increased risk of tolerance as dosage increases
2. Increased risk of abuse as dose increases
3. If response is inadequate -> consider adding a second medication (strattera, wellbutrin, SNRI’s, Intuniv (guanfacine), etc.)
86
Limit stimulant dose = max total daily dose of ___ of Adderall per day
40 mg
87
if a patient is taking Adderall XR twice a day and having trouble sleeping, you would want to try:
an XR in the morning and an IR in the afternoon or a Vyvanse in the morning.
