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What is the Central Reward Pathway?

Ventral Tegmental -> Nucleus Acumbens and PFC

Dopamine = Reward


What happens to the central reward pathway in the case of addiction?

Elevated dopamine levels -> downregulation of D2 receptors


What constitutes substance abuse?

1 of the following w/o meeting criteria for subs. dependence:
1. Recurrent use -> failure to meet obligations
2. Recurrent use in situations where physically hazardous
3. Recurrent substance related legal problems
4. Continued used despite persistent social/ personal problems caused or exacerbated by use of the substance.


What constitutes substance dependence?

3 or more of the following:
1. Tolerance
2. Withdrawal
3. Substance taken in larger amounts or over longer period of time than intended
4. Persistend desire or unsuccessful efforts to cut down or control use
5. Great deal of time spent obtaining, using, recovering
6. Important activities given up / reduced due to use
7. Continued use despite knowlege of persistent physical/ psychological problem likely caused by substance.


Do substance dependent people always have a physiological dependence?

Tolerance / Withdrawal not necessary for dependence.


polysubstance dependence

Use of substances from 3 categories (not niccotine and caffeine) - as a group meet criteria for dependence for >12 mos

Eliminated in DSM V


What effect does alcohol use have on life expectancy?

Reduces by 10 years


What constitutes moderate, at risk, and heavy drinking for males and females?

Moderate: Male: At risk: Male: 4 drinks / day or 14 drinks / week
Female: 3 drinks / day or 7 drinks / week
Heavy: Male: 5 drinks / day or 15 drinks / week
Female: 4 drinks / day or 8 drinks / week


What is a "drink"?

1 12 oz. beer
1 5 oz. glass of wine
1.5 oz. 80 proof booze


What is a blackout and what is it associated with?

Impairment of short term memory (w/ alcohol use) in with otherwise normal intellectual and cognitive ability

Associated w/ early onset drinking, high peak BAC, head trauma, sedative hypnotic use.

Not predictive of long-term impairment.


CAGE and scoring

1. Cut down
2. Annoyed by other criticizing subs. use
3. Guilt
4. Eye-opener

2+ or yes to "eye-opener" suggestive of abuse
4 is almost diagnostic of dependence


ETOH withdrawal timeline

6-8 hrs: tremors
8-12: perceptual disturbances
12-24: seizures
72: Delerium Tremens


What is the cause of death in Delerium Tremens?

Cardiovascular collapse, hypothermia


How is Delerium Tremens treated?

Prevention of alcohol withdrawal


What is the underlying cause of Wernicke's Encephalopathy?

Alcohol related Thiamine deficiency

20% mortality


What is the difference between Delerium Tremens and Alcohol Induced Psychotic Disorder?

Alcohol Induced Psychosis - clear sensorium (usually associated w/ chronic alcohol use and intox or withdrawal)
-patients alert, oriented, able to pay attention
-psychosis: delusion, hallucination, disorganization

Delerium: includes disturbance of consciousness - reduced awareness of surroundings - and change in cognition


What is the first stage of ETOH liver disease?

can occur w/ a few days of heavy drinking


What is cirrhosis?

Liver fibrosis
symptoms: general weakness, fatigue, anorexia, increased bleeding


What is the most common cause for hospitalization due to ETOH related medical condition?

Acute Pancreatitis - can lead to pancreatic insufficiency and pancreatic cancer


What is Mallory-Weiss syndrome?

Tear at gastroesophageal junction secondary to vomiting


What is the leading cause of nonischemic dilated cardiomyopathy

Prolonged excessive drinking


What cancers are associated with ETOH use?

oral, esophageal, laryngeal, stomach, colorectal, breast

-most associated w/ ETOH going down.


What changes in lab values are seen with alcohol use?

Elevated AST and ALT (esp. ratio - should be ~2)
elevated GGT
elevated MCV - macrocytic anemia due to folate def.
elevated CDT (carbohydrate deficient transferin)
elevated uric acid
elevated TG


What concern does elevated GGT raise?

associated with recent heavy drinking. concern for withdrawal


How is ETOH overdose treated?

Medical stabilization
IV fluid
Cardiovascular support

** no antidote **


What drugs can be used to treate ETOH withdrawal?



What is CIWA?

Clinical Institute Withdrawal Assessment

Useful in determining wether or not to include pharm in ETOH treatment.

Score <10 - drugs not indicated for use


2 Benzos used to treat alcohol withdrawal - pros and cons of each

Lorazepam: good for pts. w/ liver disease - minimal hepatic metabolism. Admin oral, SL, IM, IV
con: short half life -> frequent admin

Chlordiazepoxide: pro: longer half-life -> self-taper
con: long half-life -> liver disease. Oral only.


Whats the danger of ETOH withdrawal?

Autonomic instability
repeat withdrawal -> cognitive decline and increased severity of future withdrawal


What characterizes alcohol withdrawal seizures?

Generalized Tonic-Clonic
predisposition: hypokalemia, hypomagnesemia, epilepsy, previous hist. of withdrawal
manage w/ benzos. Antiepileptics may also be used.