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AUD + Cannabis Use Disorder Flashcards

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1
Q

A helpful mnemonic to remember the DSM-5 criteria for alcohol withdrawal syndrome (AWS) is HAS A PINT. Know it

A

Hallucinations
Autonomic hyperactivity
Seizures

Anxiety

Psychomotor agitation
Insomnia
Nausea/vomiting
Tremor of the hand

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2
Q

AWS symptoms peak when?

A

Day 2-3

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3
Q

What is the most serious complication of alcohol withdrawal?

A

Delirium tremens (DTs)

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4
Q

What is delirium tremens?

A

Severe confusion, disorientation, +/- hallucinations with clouding of global sensorium (decreased consciousness) + severe autonomic hyperactivity (tachycardia, HTN, hyperthermia, agitation, sweating)

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5
Q

When does delirium tremens usually begin?
How long does it last?

A
  1. Usually begins 48-96h after the last drink
  2. Lasts 1-5 days
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6
Q

What is the pathogenesis of AWS?

A

With chronic and regular alcohol use, GABA and alcohol depress the CNS, so the body makes up for it by upregulating glutamate. In a withdrawal state (where there is no alcohol), the upregulated glutamate overpowers the GABA alone and causes too much excitation

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7
Q

What are some risk factors for AWS? (5)

A
  1. ↑ quantity, frequency, and duration of alcohol use
  2. Previous alcohol withdrawal
  3. Family history of alcohol withdrawals
  4. Concurrent medical conditions
    - e.g., electrolyte imbalance 2°dehydration
  5. Consumption of sedatives/hypnotics/anxiolytics
    - i.e. concurrent withdrawal
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8
Q

List some complications associated with AWS (8)

A
  1. DEATH
  2. Brain damage
  3. Prolonged hospitalization
  4. Delirium tremens
  5. Seizures
  6. Arrhythmias
  7. Aspiration
  8. Relapse
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9
Q

The most useful screening tool for predicting a patient’s risk of developing severe complications related to alcohol withdrawal is?

A

PAWSS (Prediction of Alcohol Withdrawal Severity Scale)

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10
Q

What are 3 situations in which PAWSS might be used?

A
  1. Can be used before a patient stops or reduces drinking to determine if they are at low or high risk of severe complications of AWS (e.g. seizures, delirium tremens)
  2. Useful to help determine level of monitoring and support required
  3. Could be used in emergency room setting
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11
Q

What are the 2 major meds used for AWS?

A
  1. BZDs
    - Most commonly used
  2. Clonidine
    - Often in addition to BZDs, not typically used alone
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12
Q

What is the MOA of clonidine in AWS?

A

Suppress noradrenergic symptoms (anxiety, hypertension, tachycardia) that do not resolve with benzos
- Used for symptomatic relief

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13
Q

What are other meds to be aware of that might be used in AWS (but pretty rare) (6)

A
  1. Carbamazepine
  2. Gabapentin
  3. Baclofen
  4. Beta-blockers
  5. Haloperidol
  6. GHB
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14
Q

What is the MOA of benzos?

A

Bind to benzo binding site on GABA-A receptors to increase GABA binding affinity and increase the inhibitory action of GABA

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15
Q

Common side effects of benzos are? (4)

A
  1. Sedation
  2. Confusion
  3. Amnesia
  4. Psychomotor impairment
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16
Q

Rare side effects of benzos are? (4)

A
  1. Paradoxical reactions
  2. Falls
  3. Respiratory depression
  4. Pancytopenia
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17
Q

What scale is used in the measurement of the severity of alcohol withdrawal symptoms?

A

CIWA (Clinical Institure Withdrawal Assessment for Alcohol)

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18
Q

CIWA score ≥__ requires treatment

A

10

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19
Q

What are the 5 supportive care treatments for AWS?

A
  1. Thiamine
  2. Folate
  3. Multivitamin
  4. Electrolyte correction
  5. Fluids
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20
Q

What is the rationale behind using thiamine in AWS supportive care?

A

Prevent Wernicke-Korsakoff’s syndrome, peripheral neuropathy, and cardiomyopathy

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21
Q

What is the rationale behind using folate in AWS supportive care?

A

Prevent and correct anemia

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22
Q

What is the rationale behind using a multivitamin in AWS supportive care?

A

Prevent and correct micronutrient deficiency

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23
Q

What is the rationale behind electrolyte correction in AWS supportive care?

A

Prevent electrolyte imbalances and life-threatening complications (ex. arrhythmias, coma)

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24
Q

What is the rationale behind giving fluids in AWS supportive care?

A

Correct hypovolemia and dehydration from sweating, vomiting, diarrhea, fever

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25
Benzos and concurrent alcohol use. What is the issue?
Benzos potentiate the effects of alcohol; can lead to serious safety risks, including over-sedation, falls, delirium, respiratory depression (e.g., non-fatal or fatal overdose), and prolonged hospitalization
26
Contraindications to using benzos include? (4)
1. Severe respiratory insufficiency 2. Sleep apnea 3. Myasthenia gravis 4. Narrow angle glaucoma
27
Use caution when using benzos when? (4)
1. Lactose intolerance 2. Liver dysfunction 3. Renal impairment 4. Breast feeding
28
What are 4 receptor modulation meds that might be used in AUD?
1. Naltrexone 2. Acamprosate 3. Topiramate 4. Gabapentin
29
What are the CNS morbidities associated with AUD? (3)
1. Cognitive impairment 2. Dementia 3. Stroke
30
What are the PNS morbidities associated with AUD? (2)
1. Neuropathy 2. Myopathy
31
What are the psychiatric morbidities associated with AUD? (3)
1. Depression 2. Anxiety 3. Eating disorders
32
What are the CV morbidities associated with AUD? (4)
1. Cardiomyopathy 2. Atrial fibrilation 3. Arrhythmias 4. HTN
33
What are the GI morbidities associated with AUD? (3)
1. Alcoholic hepatitis 2. Cirrhosis 3. Pancreatitis
34
What are the cancers associated with AUD? (4)
1. Mouth 2. Esophagus 3. Pharynx 4. Larynx
35
What are the 'other' morbidities associated with AUD? (2)
1. Fetal alcohol spectrum disorders 2. Vitamin B12 deficiency
36
What role do genetics play in AUD development? (4)
1. First degree relatives - 3-4x prevalence 2. Identical twin studies - Suggest genetics account for 50% of risk 3. Children of alcohol dependent ppl adopted and raised by people not dependent on alcohol remained at ↑risk 4. Theories include polymorphisms in GABA, D4, 5-HT receptors, ADH enzyme
37
Go through the 5 steps of the transtheoretical model of behaviour change
1. Precontemplation - no recognition of need for or interest in change 2. Contemplation - thinking about changing 3. Preparation - planning for change 4. Action - adopting new habits 5. Maintenance - ongoing practice of new, healthier behaviour
38
The main concept of the transtheoretical model of behaviour change is?
Decisional Balance - "Comparing potential gains and losses” - “Weighing the pros and cons” - Balance varies depending on which stage of change the individual is in
39
What are the AUD goals of therapy? (5)
1. Prolong survival 2. Decrease morbidity and SAEs (previous list) 3. ABSTINENCE (short and long-term) 4. Minimize ADRs 5. Improve daily functioning (social, work) and QOL
40
Define alcohol use disorder
Problematic pattern of drinking with clinically significant impairment or distress
41
AUD is most common in these people/situations: (7)
1. Males 2. Middle aged (30-64y) 3. Early onset of drinking <21y 4. Single 5. Lower income 6. White or Indigenious 7. Military combat deployment
42
What are the medical clinical markers of AUD? (5)
1. MCV >96 2. Elevated GGT, AST, ALT (especially AST: ALT >2:1) 3. GERD, hypertension, diabetes, pancreatitis 4. Chronic non-cancer pain 5. Alcohol on breath
43
What are the mental clinical markers of AUD? (3)
1. Cognitive impairment or decline 2. Mood, anxiety, sleep disorder 3. Significant behavioral or academic change
44
High-risk drinking and AUD can be easily identified using simple screening tools, but...
alcohol use screening is not widely implemented in clinical practice
45
What is a standard drink for the following: Beer or cider (~5-6%) Wine (~12%) Hard alcohol (~40%)
1. 340mL can 2. 5oz 3. 1-1.5oz
46
Simplified AUD screen: How many times in the past year have you had: _ or more drink per day (men) _ or more drinks per day (women)
4 3
47
If ANY heavy drinking days in the past year (positive screen), assess drinking further. What are 3 things to determine here?
1. Determine on average how many days a week the patient has an alcoholic drink 2. Determine on a typical drinking day how many drinks they have 3. Convert response to standard drinks
48
What is a useful tool to help with engaging in AUD conversation with patients that are challenging to engage?
AUDIT (Alcohol Use Disorder Identification Tool)
49
What are the 4 Cs of addiction?
1. Loss of Control 2. Consequences 3. Compulsions 4. Cravings
50
Who are candidates for AUD treatment? (2)
1. Any patient with mod-severe AUD 2. Any patient who has undergone withdrawal management, stopped, or reduced drinking and has ongoing alcohol cravings placing them at risk of relapse
51
Goals of AUD pharmacotherapy specifically are? (3)
1. Prevent return to any drinking or return to heavy drinking 2. Reduce number of heavy drinking days 3. Reduce number of drinks per drinking day
52
What are the 2 first-line agents in AUD pharmacotherapy?
1. Naltrexone 2. Acamprosate
53
What is the MOA of naltrexone in AUD? (3)
1. Mu-opioid antagonist 2. Blocks euphoric effects of alcohol to decrease rewarding alcohol effects & reduces cravings 3. “Prevents lapse from becoming a relapse”
54
Naltrexone cannot be used with concurrent ______ use
opioid
55
Although not fully understood, what is thought to be the MOA of acamprosate in AUD? (2)
1. Thought to restore imbalance between glutamate and GABA to reduce general neuronal hyperexcitability 2. “Prevents lapse - more effective at supporting abstinence”
56
Cannot use acamprosate if CrCl ≤__ mL/min
30
57
What is the dosing of acamprosate? (Memorable one which is why I ask)
666mg TID
58
Can we use naltrexone and acamprosate together in AUD?
Studies found no increased efficacy when combined. So, theoretically, sure, we could, but we don't atm
59
What is the MOA of topiramate in AUD? (1)
Decreases craving by reducing DA release when EtOH consumed
60
How effective is topiramate in AUD?
Days abstinent at 14 weeks ↑ from 9.64% to 39.5% vs placebo ↑ from 9.35% to 29.1%
61
What is the MOA of gabapentin in AUD?
Reduces unpleasant withdrawal symptoms
62
What is the deterrent-type agent that is not really used anymore in AUD?
Disulfiram
63
What is the MOA of disulfiram? (2)
1. Aversive agent that inhibits aldehyde dehydrogenase enzyme and blocks the metabolism of alcohol 2. Results in unpleasant side effects (disulfiram reaction) if patient drinks alcohol (sweating, headache, dyspnea, flushing, sympathetic hyperactivity, nausea, vomiting)
64
Why do we no longer recommend disulfiram in AUD?
Due to severity of reaction and weak evidence of benefit
65
What are the precautions in using disulfiram in AUD? (2)
1. DO NOT start until abstained from EtOH x 12 hours minimum 2. Hepatotoxicity
66
What are the side effects of disulfiram (the med itself, not the reaction with alcohol) (6)
1. Drowsiness 2. Metallic/garlic aftertaste 3. Rash 4. Hepatitis 5. Peripheral neuropathy 6. Psychosis
67
Chronic use of cannabis may lead to the development of _________ disorders
psychotic
68
How is cannabis use disorder treated? (3)
1. Acute supportive care 2. Longer term psychosocial approaches - CBT + motivational interviewing 3. Symptomatic treatment - BZDs for anxiety - Antipsychotics for psychosis
69
What pharmacotherapy can we use for treatment of cannabis use disorder?
None established, so nothing atm, just supportive care
70
What are 2 cannabis replacement medications?
1. Dronabinol 2. Nabiximols

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