Class 5 Flashcards
(99 cards)
1
Q
Why Do People Abuse Drugs?
A
Drugs of Abuse Engage Motivation and Pleasure Pathways of the Brain.
Stress Reduction
To Feel Good To have novel: feelings, sensations, experiences AND to share them.
To Feel Better To lessen: anxiety, worries, fears, depression, hopelessness.
2
Q
Natural rewards ??? DA levels but drugs
A
elevate, are mon effective
3
Q
What is Addiction?
A
Addiction is A Brain Disease
Characterized by:
Compulsive behavior or craving
Continued abuse of drugs despite negative consequences
Persistent changes in the brains structure and function
4
Q
True or false, addiction can change biology
A
true
5
Q
Biologic changes following addiction
A
Decreased Brain Metabolism
Decreased DA transporters
Induced suppression of brain activity (ROH, cocaine)
– changes in neurotransmitter levels
– decreased dopamine D2 receptors
– low activity in the orbitofrontal cortex (OFC) and the
anterior cingulate gyrus (CG)
– inhibition of the frontal cortex – effects on memory,
decision making, inhibitory control, poor judgement,
planning and behavioural control
6
Q
Hallmark of addiction
A
loss of control of the use of substance
compulsive use or craving
continued use despite consequences
7
Q
Misuse
A
Use of medication other than as directed, whether
wilful or not.
Similar to abuse but usually applies to drugs prescribed by physicians that are then used improperly.
8
Q
Abuse
A
Maladaptive pattern of substance use leading to
clinical impairment or distress.
Use of medication for non medical purposes.
Use of any drug, usually by self administration, in a
manner that deviates from approved social or medical
patterns.
9
Q
Withdrawal
A
A substance specific syndrome that occurs after
stopping or reducing the amount of the drug or
substance that has been used regularly over a
prolonged period. This syndrome is characterized
by physiological signs and symptoms in addition to
psychological changes such as disturbances in
thinking, feeling, and behaviour.
10
Q
Intoxication
A
A reversible syndrome caused by a specific
substance that affects one or more of the following
mental functions.
11
Q
DSM 5 Definitions
Substance use disorder
A
A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by 2 or more of the following (11 symptoms) occurring
within a 12 month period:
- Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.
- Recurrent substance use in situations in which it is physically hazardous.
- Continued substance use despite having persistent and recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance. - Tolerance: Need increased amounts to achieve intoxication. Diminished effect with continued use
- Withdrawal
- Substance is often taken in larger amounts or over a longer period than was intended
- Persistent desire or unsuccessful efforts to cut down or control substance use
- A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
- Important social, occupational, or recreational activities are given up or reduced because of substance use.
- The substance use is continued despite knowledge of having persistent or recurrent physical or physiological problem that is likely to have been caused or exacerbated by the substance.
- Craving or a strong desire to use a specific substance.
Severity: Depends on the number of symptoms Mild: 2 3 Moderate: 4 5 Severe: 6 or more
Specifiers:
In early remission: no criteria for more than 3 months
but less than 12
In sustained remission: no criteria for more than 12
months
In a controlled environment
12
Q
10 Classes of Substances
A
Alcohol Caffeine Cannabis Hallucinogens: PCP, others Inhalants Opioids Sedatives, hypnotics, and anxiolytics Stimulants Tobacco Other (Gambling)
13
Q
Etiology
A
Bio: Genetics Neurotransmitters Signaling pathways Psycho: Psychodynamic Learning and conditioning: the addiction cycle Social
14
Q
Major neurotransmitter systems:
A
Dopamine: activates the reward system/triggers
GABA: indirect activation of reward system
Glutamate: reinforcement, relapse, and drug seeking
15
Q
Brain reward circuitry
A
Nucleus accumbens Locus ceruleus Prefrontal cortex Amygdala Hippocampus
16
Q
Drugs of abuse ????
natural neurotransmitters in the brain
A
resemble/activate or disrupt
17
Q
Dopamine Pathways Functions
A
- attention, arousal
- reward (motivation)
- motor function
- decision making
18
Q
Serotonin Pathways Functions
A
- mood
- memory processing
- sleep
- cognition
19
Q
Psycho : Addiction cycle
A
emotional pain = craving for relief = preoccupation with substance/ behaviour = substance use/ compulsive behaviour = short term pain relief = negative consequences resulting from behaviour = depression, guilt, shame =more pain
20
Q
Social : Addiction
A
Family Peers Societal Cultural Life events Stress Isolation
21
Q
Predisposing Factors
A
Biological factors: Genetic, 10% addicts have genetic predisposition. Familial
Psychosocial: Being a male Peer pressure Religion Home conditions Stability of parents’ marriage Cultural practices
22
Q
Precipitating factors
A
Exposure to drink or drugs for social and other
reasons
23
Q
Perpetuating factors
A
Persistent exposure
Lack of treatment
Lack of social support
24
Q
Protective Factors
A
female gender assertiveness high commitment to school high educational aspirations close affective relationships absence of parental problems high religiosity close supportive relationships with positive influencing peers high self esteem self efficiency creativity good temperament high sociability
25
Indirect stimulation of pleasure pathways: decrease background
PCP, ketamin
26
Indirect stimulation of pleasure pathways: increase signal intensity
psychadelics
27
direct interaction with pleasure pathways: primary DA effect
stimulants
28
direct interaction with pleasure pathways: primary endorphin effect
opioids
29
direct interaction with pleasure pathways: DA + GABA + endorphins
sedative hypnotics
| ROH
30
only ??? in 10 person with addiction receives treatment
1
31
Psychosocial therapies
```
Motivational
Cognitive behavioral
Community reinforcement
Contingency management
Behavioral couples family
```
32
```
NIDA: Selected Principles of
Effective Treatment (EBPs)
```
1. Addiction is a complex but treatable disease that affects brain function and behavior.
2. No single treatment is appropriate for everyone.
3. Treatment needs to be readily available.
4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.
5. Counselling individual and/or group and other behavioural therapies are the most commonly used forms of drug abuse treatment.
6. Many drug addicted individuals also have other mental disorders.
7. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long term drug abuse.
8. Treatment does not need to be voluntary to be effective.
9. Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.
33
Scientifically Based Approaches
| to Addiction Treatment
```
Cognitive behavioral interventions
Community reinforcement
Motivational enhancement therapy
12 step facilitation
Contingency management
Pharmacological therapies
Relapse Prevention
```
34
True or false: Relapse Rates Are Similar to
| Other Chronic Diseases
True
35
Management: screening
```
Clinical assessment: Don t forget, patients usually under report their use or sometimes downright lie about their use
CAGE
Screening questionnaires:
DAST
AUDIT
```
36
CAGE
Have you ever felt you should c ut down on your drinking?
Have people a nnoyed you by criticising your drinking?
Have you ever felt bad or g uilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get
rid of a hangover ( e ye opener)?
37
Stages of transtheoretical model of changes:
```
Precomtemplation
Contemplation
Decision
Action
Maintenance
Relapse
```
38
Precomtemplation
Not a problem
| Intervention: raise doubt
39
Contemplation
a problem that maybe needs to change
| Intervention: strengthen the will to change
40
Decision
something that needs to change
| Intervention: create an action plan
41
Action stage
something that is changing via abstinence
| Intervention: maintain steps in the action plan
42
Maintenance stage
no longer a problem because action is reinforced by the maintenance of a certain way of life
Intervention: avert relapse
43
Canadian standard drink sizes
13.6 grams of alcohol
12 ounces of beer = 341 mls = 1 bottle (5%)
5 ounces of wine = 150 mls (12%)
1.5 ounces of hard liquor = 45 mls (40%)
44
ROH Screening options:
| Single item screener
How many times in the last year have you had (men = 5 or more) (women = 4 or more) drinks in one occasion?”
More than once is positive screen 82% sensitive, 79% specific for unhealthy drinking (at risk and AUDs)
45
Alcohol related disorders
```
Alcohol use disorder
Alcohol intoxication
Alcohol withdrawal
Delirium
Alcohol induced persisting amnestic disorder
```
46
Short term ROH
Short term: Intoxication, injury, violence,
accidents, spousal abuse, suicide, alcohol toxicity
(overdose), death
47
Intoxication ROH
```
Problematic behaviour and psychological changes
Slurred speech
Incoordination
Unsteady gait
Nystagmus
Impaired attention or memory
Stupor or coma
```
48
Educ alcohol recommendations:
2 drinks per day max 10 per week for women
3 drinks per day max 15 per week for men
3 drinks max per day on special occasions for women
4 drinks max per day on special occasions for men
At least one day per week where no alcohol is
consumed
49
Canadian Epidemiology
| Alcohol use disorder:
2.6%
3.8% for men
1.3 for women
Province with most use: Quebec (82%)
50
Long term: ROH
Alcohol dependence, increased risk of several types
of cancer (e.g., cancers of the mouth, throat, liver,
breast, and digestive track), diabetes, cirrhosis,
pancreatitis, low birth weight, fetal alcohol spectrum
disorder (FASD).
51
Alcohol withdrawal
GABA down, Glutamate up
1. Sweating and increased pulse
2. Increased tremor
3. Insomnia
4. Nausea and vomitting
5. Hallucinations
6. Agitation
7. Tonic clonic seizures
52
Minor withdrawal ROH
autonomic symptoms
53
Major withdrawal ROH
autonomic symptoms+ hallucinations, seizures
54
4 stages of ROH withdrawal
1. autonomic symptoms: tremors 6-8h
2. Hallu: 10-30h
3. Neuronal excitation: seizures 6-48h
4. DT: 2-5 days
55
Treatment: Alcohol withdrawal
CIWA (rating scale)
Mild to moderate: no need for pharmacotherapy
Moderate to severe:
Thiamine to prevent encephalopathy
Benzodiazepine to reduce withdrawal severity
Monitoring vital parameters , with a special reference to
blood electrolytes and fluid balance (Na, K, Mg, glucose) glucose),
ECG
Benzodiazepines (diazepam [5 20 mg p.o. every 4 6
hour, starting dose of 10 30 mg i.v. if needed],
chlordiazepoxide) avoid in intoxication and long term
use, risk of respiratory depression and sedation ;
oxazepam or lorazepam if significant hepatic impairment
Thiamine for prevention of Wernicke Korsakoff syndrome
Beta blockers (e.g. propranolol or atenolol for autonomic
hyperactivity)
Valproate or carbamazepine if seizures are present
Haloperidol for hallucinations, delusions, and violence
in delirium [5 10 mg p.o. or i.m.], together with
benzodiazepines (risk of seizures and extrapyramidal
side effects)
56
Wernicke encephalopathy
Acute and reversible
Due to lack of thiamine
Confusion, ophthalmoplegia and ataxia
57
Korsakoff s syndrome
Chronic (20% recover completely)
| Amnesia, confabulation, apathy, and anosognosia
58
Treatment of alcohol use disorder 1st line
Naltrexone: Blockage of mu opioid receptor, blocks the reinforcing effect of alcohol: don’t get the buzz + less craving
Acomprosate: GABA agonist and glutamate antagonist really metabolized TID s/e: crazy diarrhea
59
Treatment of alcohol use disorder 2nd line
Disulfuram: can’t take anything with alcohol, even hand santizier
Topiramate
Gabapentin
Baclofen
60
Low risk drinking guidelines
Women: 10 drinks a week, with no more than 2 drinks a day most days, up to 3 for special occasions
Men: 15 drinks a week, with no more than 3 drinks a day
most days, up to 4 for special occasions
Elderly American guideline (no Canadian guideline)
Men no more than one per day
Women less than one per day on average
61
Cannabis related disorders
Cannabis use disorder
Cannabis intoxication
Cannabis withdrawal
62
Cannabis related disorders
| epidemiology
```
12 month prevalence
3.4% among 12 17 year olds
1.5% in adults
More males than females
Rates decrease with age
Cannabis is the most widely used illicit drug in Canada
```
63
SYNTHETIC CANNABINOIDS
Pharmacological research tools to study endocannabinoid system
Synthetic cannabinoids sprayed on herbal plants
No cannabidiol
Super agonist at CB 1 receptor
Can cause acute renal failure, hypertension,
myocardial infarction, seizures, psychosis, death
Not detected in standard urine drug screens
64
CANNABIS EFFECTS
Cannabis produces euphoria and relaxation, changes in
perception, time distortion, and deficits in attention span.
It also negatively impacts the ability to divide attention and results in deficits in memory, body tremors, and impaired motor functioning.
Cannabis also impairs coordination and balance.
Other physical effects of recent cannabis use include increased heart rate and appetite, decreased blood pressure, dilated pupils, red eyes, dry mouth and throat, and bronchodilation (expansion of breathing passages).
65
Cannabis intoxication
30 min. for peak effect
Lasts 2 4 hours
Motor and cognitive effects can last 6 12 hours
66
Effects of Cannabis oral
onset: 30 min
duration: up to 8h
subjective effects: greater bad effects
abstinence effects: less subjective abstinence effects
45% increase in appetite
67
Effects of Cannabis smoking
onset: sec
duration: 1-2h
subjective effects: greater effects on high and mellow
abstinence effects: greater effects on irritable and miserable
45% increase in appetite
68
Cannabis intoxication
```
Recent use
Behavioural or psychological changes
Two or more of the following:
Conjunctival injection
Increased appetite
Dry mouth
Tachycardia
```
69
Cannabis use disorder
| Long term effects:
Chronic cannabis use is associated with deficits in memory, attention, psychomotor speed and executive functioning, particularly among those who started using cannabis during early adolescence.
Chronic use of this drug can also increase the risk of psychosis, depression and anxiety, breathing problems and respiratory conditions, and possibly lung cancer.
Use of cannabis during pregnancy particularly heavy use
can affect children s cognitive functioning, behaviour, future substance use behaviour and mental health.
Decreases testosterone levels in men
70
Cannabis withdrawal
```
Cessation after heavy and prolonged use
Three or more of the following which develop within a week:
Irritability, anxiety, aggression
Nervousness or anxiety
Sleep difficulty
Decreased appetite or weight loss
Restlessness
Depressed mood
Abdominal pain, shakiness/tremors, sweating, fever,
chills, or headache
```
71
Treatment of cannabis use disorder
```
No effective pharmacological treatment
––? Gabapentin
Non pharmacological treatment options:
CBT
Motivational interviewing
Voucher based incentives
Peer support groups
Family therapy
```
72
Opioid related disorders
Opioid use disorder
Opioid intoxication
Opioid withdrawal
73
Opioid def
Definition: Natural and man made chemicals that act at opioid receptors to produce morphine like effects
74
Opioid types
Natural: codeine, morphine
Semi synthetic: diacetylmorphine (heroin), hydromorphone, oxycodone, buprenorphine
Synthetic: fentanyl, methadone, meperidine
Endogenous: Endorphins
75
opioid prevalence
0.5 3% of Canadians are currently using opioids
76
Opioid intoxication
```
Problematic behaviour or psychological changes
Pupillary constriction
Drowsiness and coma
Slurred speech
Impaired orientation and memory
```
77
Opioid use disorder
| Long term effects
Opioids can reduce pain and improve function.
Opioids can also produce a feeling of well being or euphoria high ””).
At sufficiently high doses, opioids cause drowsiness, coma, and death.
Other physical effects are constricted pupils, a slight decrease in respiratory rate, nausea, vomiting, constipation, loss of appetite, and sweating.
Narcotic bowel syndrome: increased abdominal pain with
increasing doses of opioids.
Opioids can also cause increased risk of sleep apnea, mood changes, decreased sex hormone levels resulting in decreased interest in sex and menstrual irregularities, physical dependence, and addiction.
Regular use of large quantities of opioids during pregnancy increases the risk of premature delivery and withdrawal in the infant.
In those people who crush and inject oral opioids, certain filler chemicals in the pills can permanently damage veins and organs.
Sharing needles or injecting with previously used needles greatly increases the risk of getting certain infections (e.g., HIV, hepatitis C).
78
Symptoms of opioid withdrawal
```
Dysphoria
N o/Vo
Muscle aches
Lacrimation/rhinorrhea
Pupillary dilation, pilo erection or sweating
Diarrhea
Yawning
Fever
Insomnia
```
79
Treatment opioids
Pharmacological treatments
Methadone (agonist)
Buprenorphine (agonist)
Naltrexone (antagonist)
Non pharmacological treatments
Individual or group counselling
Peer support groups
Abstinence based treatments
80
Stimulant related disorders
Stimulant use disorder
Stimulant intoxication
Stimulant withdrawal
81
COMMON
| STIMULANTS
```
Cocaine
Crack cocaine
Methamphetamines
Amphetamines
MDMA (Ecstasy)
Prescription stimulants
Methylphenidate
Dextroamphetamine
Modafinil
Caffeine
Ephedrine
Cathinone ( Khat)
```
82
Prevalence of Stimulant Use
Canadian cocaine use ~1.5 % (past year use
| Canadian Drug Summary 2017
83
Mechanism of Action
| Cocaine
```
blocks catecholamine ( dopamine ,
adrenaline, noradrenaline) reuptake
```
84
Mechanism of Action Methamphetamines
blocks dopamine reuptake AND promotes direct dopamine release
85
Mechanism of Action MDMA
increases serotonin by blocking reuptake and directly releasing
86
Effects of stimulant use
| Short term:
Cocaine use can cause increased energy and
alertness, euphoria, increased body
temperature, increased heart rate and blood
pressure, agitation, paranoia, suppressed
appetite, muscle spasticity, stroke, fainting,
and overdose.
87
Cocaine An overdose
can involve a seizure, heart failure, and respiratory suppression.
88
Effects of Stimulant Use
| Long term:
Longer term effects of cocaine use are sleep
disturbance, weight loss, tolerance, depression,
cardio vascular problems, nasal damage (through
snorting), throat and bronchial damage (through crack
smoking), headaches, hallucinations, seizure,
attention and memory disruption, and low birth weight
of children born to mothers who use cocaine during
pregnancy
89
Treatment stimulants
```
Non pharmacological treatment:
Contingency management: voucher based
Psychotherapies:
CBT
Motivational interviewing
Pharmacological treatment:
None proven effective
```
90
Sedative --,hypnotic --, or anxiolytic related disorders
Sedative --, hypnotic --, or anxiolytic use disorder
Sedative --, hypnotic --, or anxiolytic intoxication
Sedative --, hypnotic --, or anxiolytic withdrawal
91
Types of Sedative --, hypnotic --, or anxiolytics
Benzos, barbiturates, non benzo sleep rx
92
Benzodiazepines (BZD):
| mechanism of action
```
Enhance GABA activity
GABA is the major inhibitory neurotransmitter of the
CNS, it decreases neuronal excitation
GABA A : depressant effect
Benzodiazepine ( Bz ) receptors
Bz 1 : Sleep inducing effect
Site of action of zolpidem
Bz 2 and Bz 3 : antiseizure , antianxiety and muscle
relaxation effects
```
93
Sedatives and Tranquilizers use disorder prevalence
Prevalence:
12 17 year olds: 0.3%
18+: 0.2%
94
Effects of Sedative and Tranquilizer Use
| Short term:
These medications increase the activity of the neurotransmitter gamma aminobutyric acid (GABA), which causes a decrease in brain activity.
Low to moderate doses of sedatives and tranquilizers can relieve mild to moderate anxiety and have a calming and relaxing effect.
Higher doses of these medications can relieve insomnia and severe states of emotional distress, and result in drowsiness and impaired coordination.
Other short term effects of sedatives and tranquilizers include dilated pupils, slurred speech, irregular breathing, decreased heart rate and blood pressure, loss of inhibition, and impaired judgment, learning, and memory.
These medications can also cause side effects such as confusion, disorientation, amnesia, depression and dizziness.
95
Effects of Sedative and Tranquilizer Use Long term
term: The long term effects of sedatives and
tranquilizers can include chronic fatigue, vision
problems, mood swings, aggressive behaviour,
slowed reflexes, breathing problems, death due to
respiratory depression, liver damage, sleep
problems, and sexual dysfunction.
These drugs also have the potential for addiction
and this risk is amplified when they are misused.
96
Benzodiazepine withdrawal
```
Symptoms are likely to include
Headaches and anxiety
Insomnia
Tremors
Fatigue
Perceptual changes
Tinnitus
Sweating
Decrease concentration
Abrupt abstinence after higher doses could cause
delirium and seizures
Irritability
```
97
Benzodiazepine withdrawal SIGNS / COMPLICATIONS
```
Autonomic hyperactivity
(diaphoresis, tremor, tachycardia, HTN)
Hyperreflexia,
Mydriasis
Seizures, Arrythmias
Psychosis, Delirium
Suicidal Ideation
```
98
Sedative and Tranquilizer Treatment
Pharmacological management
Medication tapering
Switching to long acting benzodiazepine
```
Non Pharmacological management
Peer support
Individual or group psychotherapy
CBT
Motivational interviewing
```
99
???? withdrawal are potentially deadly.
Alcohol and benzodiazepine
