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Lecture 10: Substance Abuse Part 2 COPY Flashcards

1
Q

What is the #1 preventable cause of death in the US? How many deaths does it cause?

A

Smoking.
1 in 5 of all deaths in the US are due to smoking.

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2
Q

What gender is smoking more prevalent in? How prevalent is it in WV?

A

Higher in men.

Nationwide is 11.5% for adults, but WV is 24%!!!

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3
Q

What other forms of tobacco exist outside of cigarettes?

A

Cigars/pipes (slightly lower risks of lung cancer)
Hookahs
Smokeless tobacco
E-cigs/Vaping

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4
Q

What demographic is MC for smokeless tobacco use?

A

White males of low socioeconomic status in southern US

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5
Q

What does vaping aerosolize?

A

Nicotine.

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6
Q

What is EVALI?

A

E-vaping associated lung injury.
It is an acute eosinophilic pneumonia.

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7
Q

How much nicotine is in a cigarette? Is absorption of nicotine higher in vaping or smoking?

A

10-15mg of nicotine in the avg cigarette.

Vaping absorbs 2-3x MORE NICOTINE.

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8
Q

What does nicotine do?

A

A highly addictive substance that stimulates nicotinic cholinergic receptors in the brain.

Releases dopamine and epinephrine release.

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9
Q

How fast is the onset of nicotine? Half-life?

A

15s onset to reach the brain.
Half-life of 1-2 hours.

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10
Q

What happens as someone continues to absorb nicotine?

A

Tolerance develops as there is an upregulation of nictonic receptors.

In withdrawal, there will be even less dopamine and less epinephrine.

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11
Q

What are the acute toxic effects of tobacco-related disorders?

A

Nausea, Salivation, Pallor
Tachycardia, poor concentration
Decreased REM sleep

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12
Q

What are the harmful effects of smoking?

A

All-causes!!!
Cancer, pulmonary, periodontal, immunologic, endocrine, MSK, reproductive, GI, Postop

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13
Q

What treatment does smoking increase the failure rate of?

A

H. pylori treatment

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14
Q

How can we detect tobacco use lab-wise?

A

Serum continine
Anabasine

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15
Q

What is continine?

A

A nicotine metabolite, present in the serum for 2/3 a day and in urine for weeks.
However, you can pick it up from secondhand smoke.

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16
Q

What is anabasine?

A

A product found in tobacco and vapes but not nicotine replacement.
You rarely pick it up from secondhand smoke.

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17
Q

Which lab test for tobacco use is more common?

A

Continine, but it is less accurate. (since you can pick it up from secondhand smoke.)

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18
Q

What are some ways we screen for tobacco use?

A

Cigarette smell
Tobacco staining on the tongue, teeth, or FINGERS (rollers)
Pharyngeal erythema
Increased carbon monoxide
Lab tests

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19
Q

What is the recommended treatment for adolescents wishing to quit smoking?

A

Nicotine replacement therapy.(NRT)

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20
Q

How is NRT dosed usually?

A

Long-acting patch + short acting oral

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21
Q

What is the simplest method of NRT?

A

Nicotine transdermal patch once a morning.

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22
Q

What counseling education should I provide a pt using nicotine patches?

A

Rotate it every morning to NON-HAIRY skin.
DO NOT LEAVE ON OVERNIGHT

Your skin may be irritated.
Possible insomnia and vivid dreams.

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23
Q

What is nicotine gum primarily used for?

A

Diminishing the withdrawal symptoms. (DOES NOT STOP WITHDRAWAL SYMPTOMS)

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24
Q

What counseling education should I provide a pt using nicotine gum?

A

Avoid acidic beverages before and during gum use.
You want to chew it until a peppery taste appears, then park it in your mouth. Resume chewing once the taste disappears and repeat until there is no more peppery taste.

Note:
Pepper taste/Slight tingling means the nicotine is released.

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25
What kind of patients cannot use nicotine gum?
TMJ Poor dentition Dental appliances
26
What is a nicotine lozenge?
An oral lozenge that contains the highest amount of nicotine.
27
What counseling education should I provide a pt using oral nicotine lozenges?
DO NOT SWALLOW (just let it dissolve) Reduce use of lozenges over time.
28
What is a nicotine inhaler?
Used for satisfying the sensory and behavioral cravings.
29
What kind of patients cannot use a nicotine inhaler?
Reactive airway diseases (Asthma)
30
What is a nicotine nasal spray?
IN administration that gives a faster peak than oral nicotine.
31
What is wellbutrin/bupropion's MOA?
Blocks dopamine and NE reuptake (DNRI) Antagonizes nicotinic cholinergic receptors (SR form recommended).
32
What are the SE of wellbutrin/bupropion?
Insomnia Agitation Dry mouth HA Seizure (Rare and dose-dependent)
33
What kind of patients cannot take wellbutrin/bupropion?
Epileptics High seizure risks Hx of anorexia or bulimia
34
What is chantix/varenicline's MOA?
Partial agonist of nicotinic receptors. It only does partial stimulation, so you don't feel as rewarded, but you also don't get withdrawals as bad.
35
When do I need to reduce chantix dosing?
Renal insufficiency.
36
What kind of patients cannot take Chantix?
Hypersensitivity or skin reaction to rx.
37
What is an emerging therapy for tobacco use?
Nicotine vaccine! The antibodies will bind nicotine and stop it from crossing the BBB.
38
What should a patient expect post tobacco cessation?
Weight gain Depression and anxiety Increased cough and mouth ulcers
39
How common is heroin use?
2.1% of pts 12+ y/o
40
What are the types of opiates?
Natural: Codeine and morphine (Straight from the poppy plant) Semi-synthetic: Everything else Synthetic: Meperidine, fentanyl, methadone Endogenous opioids: Endorphins, enkephalins, dynorphins, endomorphins Other: Tramadol
41
What are the 3 types of opioid receptors in the body?
Mu - pain, resp depression, constipation, physical dependence. Kappa - Analgesia, diuresis, sedation, psychological dependence Delta - analgesia, dependence, antidepressant
42
Where are opioid receptors found in the body?
Brain Digestive Tract Spinal Cord
43
What are 3 general positive effects of opioids?
Pain (analgesic effect) Antitussive (Codeine is in cough syrup) Psychiatric (euphoria, anxiolysis)
44
What is indicative of mild opioid intoxication?
PUPILLARY CONSTRICTION CONSTIPATION
45
What is suggestive of severe opioid intoxication?
Respiration depression Pinpoint pupils
46
What is narcan/naloxone used for?
Short-acting opioid antagonist.
47
What should you consider if narcan doesn't work? What should you then do?
Consider other substances. CPR may be indicated as well.
48
What does long-term use of opioids do to the receptors?
Desensitization and downregulation (Opposite of nicotine!!!!!!)
49
What kind of opioids produce tolerance more?
Short-acting, such as morphine or heroin.
50
How many grades of opioid withdrawal are there? What grade should we treat at?
0-4. Treat at grade 2, which is mydriasis, piloerection, anorexia, TREMORS, HOT AND COLD FLASHES, generalized aching.
51
What opioid has an extremely long half-life?
Methadone
52
How do people undergoing opioid withdrawal typically act?
Rebound hyperactivity for 3-6 months. Restless, irriitable, and poor concentration.
53
How do you treat acute opioid withdrawal?
Methadone Buprenorphine Alpha-2 agonists (Clonidine, Lofexidine)
54
What is clonidine CId in?
Hypotensive patients. It drops BP a lot as well.
55
What antagonist treatment is indicated for maintenance in chronic opioid use?
Naltrexone. Cannot be used for acute tx.
56
What is nice about naltrexone dosing?
Can be given IM once a month.
57
What is the BBW of naltrexone?
Hepatocellular injury. Also, if someone goes back on opioids while on naltrexone, they might OD by accident because naltrexone is an antagonist.
58
What agonist treatment is indicated for chronic opioid use?
Methadone! Helps decrease withdrawal s/s and blocks the high from acute use.
59
Why might patients accidentally OD while on methadone?
Methadone has a slow onset, so patients might get impatient waiting for it to take effect or think its not working.
60
How does one qualify for methadone tx?
Must meet at least 1 of 4 criteria: 1+ yr of opioid use. Hx of methadone maintenance and showing signs of imminent return to dependence. Recently released from hospital/prison with hx of dependence. Pregnant and opioid dependent.
61
What opioid agonist combo discourages abuse?
Buprenorphine + naloxone (Suboxone)
62
How is suboxone given?
Long acting implant or TAKE HOME THERAPY (low abuse potential)
63
What are the non-pharmacological treatment options for opioid use?
CBT Insight oriented therapy Resident programs Peer support groups
64
What do psychostimulants do?
Cause a release and block the reuptake of Dopamine, NE, and serotonin.
65
What are the psychostimulants (legal and illegal)?
Meth MDMA (Ecstasy) Ephedrine ADHD meds
66
Where do psychostimulants tend to accumulate?
In the brain (10x more than plasma)
67
What are the two most common ways psychostimulants are taken?
Smoking Snorting
68
What is a key difference between acute amphetamine intoxication vs opioid?
DILATED pupils in amphetamines. PINPOINT pupils in opioids.
69
How do we treat amphetamine intoxication?
Symptomatic treatment. Sedation/seizure control via IV Benzos (Haldol) Airway management AntiHTNs Hyperthermia (cooling blankets, ice packs, NO ANTIPYRETICS) Fluids
70
Why are antipyretics not indicated in amphetamine treatment protocols?
The hyperthermia is due to muscle ridigity, not fever.
71
What can amphetamines have cross-sensitivity with?
Cocaine
72
How does long term amphetamine use cause motor and cognitive deficits?
Decreased dopamine receptors in the basal ganglia lead to motor deficits. Decreased metabolic rate in the prefrontal cortex leads to cognitive deficits.
73
Whats the main drug class we use for anyone in amphetamine withdrawal?
Benzos. There is no general proven med treatment regimen.
74
What are the pharmacologic options for treating chronic amphetamine use?
Bupropion + naltrexone (First-line) Mirtazapine (2nd line) Adjuncts/alts: Methylphenidate (stimulant), topamax (Anticonvulsant)
75
What is the MC abused anxiolytic?
Benzos
76
What is the MOA of benzos?
Enhancing the effect of GABA (Inhibitory NT)
77
When are benzos indicated?
Sedation Sleep-induction Anticonvulsant Anxiolytic Muscle relaxant Alcohol withdrawal
78
What does chronic benzo use do?
Changes GABA receptor structure, leading to decreased affinity.
79
What will just a benzo OD present as?
CNS depression with normal vitals.
80
How do benzo ODs usually present in real life?
With alcohol as well, leading to CNS depression AND respiratory depression.
81
What is the treatment protocol for anxiolytic OD?
Airway Breathing Circulation
82
What medication is used to treat anxiolytic OD?
Flumazenil (controversial competitive antagonist of GABA receptors) May precipitate withdrawal seizures.
83
How is anxiolytic withdrawal treated?
Long-acting Benzos. (best for overall treatment) Withdrawal from chronic benzo use can be very dangerous, so treatment requires precision.
84
How are benzos titrated for chronic anxiolytic use?
Tapering over 6-12 months. (Diazepam, chlordiazepoxide) Withdrawal is very dangerous!!
85
What does cocaine do?
Blocks dopamine reuptake. The purer it is, the more intense the high.
86
What is a unique effect of snorting cocaine?
Local vasoconstriction. Cocaine can be used in the ER to treat epistaxis.
87
Use of what with cocaine can produce more intense and longer-lasting effects?
Alcohol
88
What CV effect does cocaine use cause that is very dangerous?
MI, even without any risk factors.
89
How is acute cocaine withdrawal treated?
Acute withdrawal requires a dopamine agonist like bromocriptine. Antipsychotics for the other SE.
90
How is chronic cocaine use treated?
Topamax (First-line) Dopamine agonists/stimulants (Dextrometh, meth, modafinil) Disulfiram TA-CD Vaccine (Emerging therapy)
91
What are the two primary things in marijuana?
THC (psychoactive agent) CBD (Cannabidiol)
92
What does marijuana mimic in the body?
Anandamide. Increases dopamine levels.
93
Why is smoking marijuana a concern pulmonary wise?
Has nearly all of the same combusted particles of tobacco smoke without the filter.
94
What is cannabis hyperemesis syndrome?
N/V/D + Abd pain from hx of chronic cannabis use.
95
How is cannabis hyperemesis syndrome treated?
Taking a hot shower/bath Not taking cannabinoids, mainly the THC component.
96
What is the goal of marijuana treatment?
Sustained abstinence. Psychosocial intervention is preferred over medications.
97
What are possible meds for treating marijuana use?
Acetylcysteine Gabapentin Topamax Varenicline (Chantix)
98
What are the schedules of the DEA drugs? Which has the most abuse & dependence potential?
Schedule 1 is the most potential. There is schedule 1-5 for controlled substances.
99
What notable drugs fall under schedule I?
Heroin LSD Marijuana Ecstasy Peyote (a spineless cactus lol)
100
What notable drugs fall under schedule II?
ADHD meds Opioids (hydrocodone products must be <15 mg) Cocaine
101
What notable drugs fall under schedule III?
Tylenol #3 + codeine Ketamine Testosterone
102
What notable drugs fall under schedule IV?
Benzos Tramadol, Soma, Ambien, Lunesta
103
What notable drugs fall under schedule V?
Antidiarrheals, antittusives, or analgesics Cough syrups with < 200mg of codeine per 100mL Lomotil, Lyrica, Neurontin (state-dependent)
104
At what schedule do drugs not get refills unless you're in pain management?
Schedule II. Example: In WV, PAs can write a 3-day supply with 0 refills.

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