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Psychiatry > Substance abuse > Flashcards

Substance abuse Flashcards

1
Q

Describe the DSM-V criteria for alcohol use disorder?

A

DSM-V criteria: (same general criteria for all substance abuse)
• Two or more of the following (within 12 months):
- Alcohol taken in larger amounts over a longer period of time than was intended
- Persistent desire or unsuccessful efforts to cut down or control alcohol use
- A great deal of time spent obtaining alcohol, using alcohol or recovering from the effects
- Craving or a strong desire to use alcohol
- Recurrent alcohol use resulting in failure to fulfil major obligations at work, school or home
- Continue alcohol use despite have persistent or recurrent social or interpersonal problems caused by alcohol
- Important social, occupational or recreational activities given up or reduced because of alcohol use
- Alcohol use continued despite the knowledge that it causes or worsens physical or psychological problems (e.g. ulcer disease, depression)
- Tolerance for alcohol
- Withdrawal symptoms (e.g. elevated vital signs, tremors, delirium tremens, seizures)

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2
Q

Describe the complications of alcohol intoxication?

A

Hypoglycaemia, memory impairment (anterograde amnesia, alcoholic blackouts), respiratory failure, coma, death, trauma

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3
Q

Describe the complications of alcohol withdrawal?

A
  • Withdrawal symptoms/sympathetic nervous system stimulation (elevated vitals, diaphoresis, flushing, tremor, insomnia, anxiety- 1-4 days post cessation or reduction)
  • Withdrawal seizures (12-24hrs post last drink)
  • Delirium tremens (24-96hrs after last drink, fluctuating consciousness, disorientation, elevated vital signs, tremors)
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4
Q

Describe the physiological complications of alcohol use.

A
  • GI; hepatitis, hepatic cirrhosis, malabsorption leading to vitamin deficiencies (esp B), oesophageal varices, pancreatitis
  • Neuro; Wernicke encephalopathy (usually reversible- triad of delirium, ataxia, ophthalmoplegia), Korsakoff syndrome (irreversible- anterograde amnesia, confabulation), cerebellar degeneration, peripheral neuropathy, hepatic encephalopathy, alcohol-induced persisting amnesic disorder
  • CVS; cardiomyopathy
  • Haem; macrocytic anaemia (increased MCV)
  • Psychiatric; alcohol-induced psychosis, mood/anxiety/sleep disorders
  • Other; alcohol-induced sexual dysfunction, foetal alcohol syndrome (LBW, intellection disability, facial and cardiac abnormalities)
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5
Q

Describe the treatment of alcohol abuse disorder.

A

Non-pharm:
- Goal is the pt regaining control of their alcohol use, best achieved through total abstinence and relapse prevention
- Mainstay of treating alcohol withdrawal is benzodiazepines (e.g. lorazepam), either tapering over several days or with symptom-triggered approach (AWS)
- 12-step programs are beneficial, addressing issues such as denial of addiction, feelings of responsibility/shame, discouraging enabling behaviour of loved ones, establishing social support systems (sponsor), sense of hope in community
- Vitamin supplementation; notably decreased thiamine due to decreased absorption and poor nutrition.
–> Acute thiamine depletion causes Wernicke’s encephalopathy
–> Chronic thiamine depletion causes Korsakoff syndrome
–> In both, IV thiamine should be given, PRIOR to IV glucose (administering glucose in thiamine-deficient state will exacerbate process of cell death and worsen the condition)
Pharm:
- 1st line: naltrexone and acamprosate
- 2nd line: Disulfiram, Topiramate and gabapentin

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6
Q

What is the DSM-V criteria for stimulant intoxication?

A

A. Recent use of a stimulant
B. Clinically significant maladaptive behaviour or psychological changes that developed during or shortly after use of substance
C. Two or more symptoms that develop during or shortly after use of the amphetamine or related substance, such as;
1. Change in heart rate
2. Pupil dilation
3. BP change
4. Perspiration or chills
5. Nausea or vomiting
6. Weight loss
7. Psychomotor agitation or retardation
8. Muscular weakness, respiratory depression, chest pain, arrhythmias
9. Confusion, seizures, dyskinesia, dystonia, coma
D. The symptoms are NOT cause by another medical or psychiatric condition

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7
Q

Describe the behavioural and physical changes of stimulant use?

A

• Stimulant behavioural changes;

  • Euphoria or blunting
  • Hypervigilance or hypersensitivity
  • Heightened anxiety or irritability/anger
  • Stereotyped behaviours
  • Impaired judgement

• Stimulant physical changes;

  • Mydriasis (dilated pupils)
  • Autonomic instability (BP low/high, HR low/high)
  • Chills or sweating
  • Nausea or vomiting
  • Psychomotor agitation/retardation
  • Muscle weakness
  • Chest pain or arrhythmias
  • Confusion, seizures, stupor, dystonias, coma
  • Weight loss, loss of appetite
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8
Q

Describe the effects of cocaine withdrawal.

A

Cocaine withdrawal (“crash”, lasts 2-4 days); dysphoria, excessive sleepiness, fatigue, increased appetite, psychomotor agitation or retardation, vivid/unpleasant dreams, insomnia or hypersomnia, cravings, depressed mood, suicidal ideation

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9
Q

Describe the psychological effects of cocaine intoxication.

A

Cocaine intoxication; hallucinations (visual and auditory), paranoia, delusions, risk-taking behaviour

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10
Q

Describe the DDx of cocaine intoxication.

A
  • Difficult to differentiate between primary mood or psychotics disorders and stimulant use disorders. Diagnosis requires a period of abstinence up to several months
  • Opioid withdrawal; diarrhoea, piloerection, yawning
  • Sedative-hypnotic withdrawal; postural hypotension, psychomotor agitation, insomnia
  • ETOH withdrawal; tremor, headache, hypotension
  • Delirium tremens; delirium, autonomic hyperactivity, visual or tactile hallucinations
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11
Q

Describe the acute and chronic treatment of cocaine intoxication.

A

Acute
• Stimulant intoxication generally supportive
• Symptoms of intoxication clear in 48hrs
• Withdrawal is time limited and treatment not needed unless depressed mood is severe
• Antidepressant recommended if depressed mood does not clear within several weeks
• Antipsychotics and/or restraints are recommended in cases of psychosis or violent behaviour
• Hospitalisation may be necessary if delusions or paranoia are present and/or if pt is a danger to themselves or others

Long-term
• Multimodal; medical, psychological, social
• Goal is to establish and maintain abstinence
• Residential inpatient setting may be required to establish abstinence initially
• Frequent unscheduled urine tox screening aids abstinence maintenance
• Individual and group therapies (e.g. Narcotics Anonymous); focus on support, education, reduction of denial, building coping skills to avoid further drug use
• Behavioural therapies (e.g. clinical management, coping skill approaches, motivational interviewing) have all shown benefit in reducing drug use
• Family therapy; confronting pt with effects of their drug-addicted behaviour, and the family with ways they enabled this

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12
Q

How does opioid intoxication present?

A

Opioid intoxication: apathy, psychomotor retardation, constricted pupils, drowsiness

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13
Q

How does opioid overdose present?

A

Opioid overdose; pinpoint pupils, bradycardia, orthostatic hypotension, respiratory depression

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14
Q

How does opioid withdrawal present?

A

Opioid withdrawal; N/V, muscle aches, lacrimation, rhinorrhoea, diarrhoea, diaphoresis, chills, autonomic hyperactivity (fever), dilated pupils, sweating, piloerection, depressed or anxious mood, yawning, insomnia
–> Opioid withdrawal mnemonic ‘SLUDGE’: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis

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15
Q

List the DDx of opioid withdrawal?

A

DDx:

  • Alcohol and/or benzodiazepine withdrawal; can similarly demonstrate autonomic hyperactivity, but also anxiety, restlessness, irritability, insomnia, hyperreflexia, tremor, hallucinations, illusions, seizures, delirium and death
  • Stimulant withdrawal; “crash”, fatigue, vivid or unpleasant dreams, insomnia or hypersomnia, hyperphagia, psychomotor agitation or retardation, depressed mood
  • Tobacco withdrawal; anxiety, depression, irritability, poor concentration, increased appetite, restlessness, sleep disturbances
  • Opioid withdrawal; does not cause tremors, confusion, delirium or seizures (seldom causes lethargic, tired)
  • Opioid overdose; pinpoint pupils, bradycardia, orthostatic hypotension, respiratory depression
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16
Q

Describe the treatment of opioid withdrawal?

A

Treatment:

  • Duration of action; the shorter the duration of action of the drug ingested, the more acute/intense the withdrawal (reverse is also true)
  • Exception; when an opioid antagonist (e.g. naltrexone) given to a person dependent on a long-acting opioid -> withdrawal will be severe
  • Often give clonidine to treat many of the withdrawal symptoms, along with the short-term administration and gradual tapering of methadone or buprenorphine
17
Q

What are some supportive treatments of opioid withdrawal?

A 
o	Dicyclomine; abdo cramps
o	Loperamide; diarrhoea
o	Methocarbamol; muscle cramps
o	Ibuprofen; muscle aches
o	Ondansetron or promethazine; N/V
o	Decongestants; rhinorrhoea
18
Q

Describe the clinical presentation of tobacco withdrawal symptoms?

A
  • Psychological symptoms; anxiety, anger, depression, irritability
  • Physical symptoms; increased appetite, insomnia, restlessness, decreased concentration
19
Q

Describe some of the medical consequences of tobacco use?

A
  • Cancers (e.g. neck, larynx, throat, lung, kidney, liver, bladder, cervix)
  • Vascular; stroke, aneurysm, coronary artery disease, PVD, cataracts
  • Respiratory; COPD
  • Genitourinary; ectopic pregnancy, infertility, erectile dysfunction,
  • Endocrine; diabetes
  • Perinatal; low birth weight, miscarriage
20
Q

Outline the treatment for tobacco use disorder?

A

• Most effective treatment combines behavioural and pharmacological interventions (e.g. group therapy plus NRT)
Non-pharm:
o Counselling, e.g. clinician, group therapy, skills training, apps, text-based coaching
o Social support, e.g. family and friends
o CBT; managing symptoms, providing support to stop
Pharm:
o Nicotine Replacement Therapy (NRT) (e.g. patch, gum, lozenge, inhaler, spray). Often benefit in combining long acting replacement (e.g. patch) with short-acting formulation (e.g. gum) to combat acute cravings that break through
–> NRT may be combined with other medications such a bupropion and varenicline

21
Q

What is the DSM-V criteria for PCP intoxication?

A

DSM-V criteria:
• Recent use of PCP or similar substance
• Disturbed behaviour such as hostility, violence, impulsivity, psychomotor agitation after ingestion of PCP
• Two or more of the following, within 1 hr of ingestion:
- Ataxia
- Dysarthria
- Hyperacusis (sensitive hearing)
- HTN or tachycardia
- Numbness
- Muscle rigidity
- Nystagmus; rhythmic, oscillating motion of the eyes, can be horizontal (most common), rotary (classic) or vertical
- Seizures or coma
• The symptoms are NOT secondary to a medical condition or mental illness

22
Q

List the DDx for PCP intoxication?

A

DDx:
• Manic episode of bipolar disorder
• Psychotic decompensation of schizophrenia
• Brief episode of psychosis
• Intoxication by other sedatives, stimulants or narcotics (esp hallucinogens, amphetamines, ketamine)
• Opioid withdrawal; dilated pupils, tachycardia, rhinorrhoea
• Opioid overdose; pinpoint pupils, bradycardia, orthostatic hypotension, respiratory depression
• Carbon monoxide and methanol poisoning; ocular nerve palsy and cardiac arrhythmias
• Rohypnol (Flunitrazepam); hallucinations, heart block

23
Q

Describe the treatment for PCP intoxication?

A

PCP intoxication is a psychiatric emergency due to potential for psychosis and safety risk (to pt and staff)
Non-pharm:
- Keep in low stimulus environment (dark, quiet, calm)
- Avoid physical restraints as necessary due to risk of muscle breakdown
- NOT gastric lavage (risk aspiration) or urine acidification (risk ATN)
Pharm:
- 1st line: benzos in non-psychotics
- antipsychotics if psychotic/agitated (e.g. haloperidol)
–> Note there is a risk of increasing PCP-induced hyperthermia, dystonia, anticholinergic reactions and lowering the seizure threshold. So, must avoid typical low-potency antipsychotics (e.g. chlorpromazine)

24
Q

Outline the DSM-V criteria for alcohol withdrawal?

A

DSM-V criteria:
• Cessation or reduction in heavy, prolonged alcohol use.
• Two or more of the following, developing within hours to days:
- Agitation
- Anxiety
- Autonomic hyperactivity (vital signs elevated)
- Hand tremor
- Insomnia
- Nausea/vomiting
- Seizures
- Transient hallucinations
• The symptoms cause distress or impairment in functioning
• The symptoms are not due to a general medical condition or another mental illness

25
Q

Outline the stages of alcohol withdrawal? When do seizures and DTs occur?

A

o 6-8hrs: tremulous and jittery
o 8-12hrs: perceptual disturbances and psychosis
o 12-24hrs: seizures
o 24-72hrs, up to a week: delirium tremens (DTs)

26
Q

How do you treat alcohol withdrawal?

A
  1. Benzos
    –> If liver function intact: long-acting benzo (e.g. diazepam)
    –> Decreased liver function: lorazepam or oxazepam (metabolism less dependent on liver)
    –> given as frequently as necessary to normalise vital signs and sedate pt, using AWS. Taper over several days
  2. Anticonvulsants
  3. Refractory DTs -> sedation with phenobarbital (barbiturate) or propofol
    Note: Antipsychotics should NOT be used (potential to lower seizure threshold)
27
Q

Describe the DSM-V criteria for anxiolytic withdrawal?

A

DSM-V criteria for anxiolytic withdrawal:
• Cessation or reduction in the use of an anxiolytic drug.
• Two or more of the following (occurring post cessation): autonomic hyperactivity, hand tremor, insomnia, N/V, hallucinations, psychomotor agitation, anxiety, grand mal seizures
• Symptoms should not be due to a general medical condition.

28
Q

Differentiate between withdrawal from anxiolytics, opioids, cocaine and alcohol?

A
  • Anxiolytics withdrawal; anxiety, photophobia, intolerance to loud noise, muscle twitching, N/V, diaphoresis, seizures
  • Opioid withdrawal; abdominal and muscle pains, salivation, lacrimation, rhinorrhoea, yawning, piloerection, diarrhoea
  • Cocaine withdrawal; “crash”, hypersomnia, hyperphagic, strong craving for drug
  • Alcohol withdrawal; similar to benzo withdrawal (same criteria) but requires hx of heavy, sustained ETOH use
29
Q

How do you treat anxiolytic withdrawal?

A
  • Gradual tapering of Benzodiazepine to prevent further seizures (NOT abrupt cessation)
  • In pts with liver disease, benzos primarily metabolised by phase II enzymes should be used (e.g. lorazepam, oxazepam, temazepam) as phase I metabolism generally reduced in chronic liver disease
  • Addition of carbamazepine; preventing withdrawal seizures in individuals prone to developing them

Note: Flumazenil; benzo receptor antagonist used in benzo overdoses, precipitates withdrawal

30
Q

Outline the DSM-V criteria for cannabis intoxication?

A

DSM-V criteria for cannabis intoxication:
• Recent use of cannabis.
• Clinically significant problematic behavioural or psychological change(s) that developed during or shortly after cannabis use.
• Two or more of the following signs, developed within 2hrs of use:
1. Conjunctival injection
2. Dry mouth
3. Increased appetite
4. Tachycardia
• Symptoms are NOT due to a general medical condition, another mental disorder or another substance use.
• Specify: if with perceptual disturbances; hallucinations with intact reality testing.

31
Q

Outline the DSM-V criteria for cannabis withdrawal?

A

DSM-V criteria for cannabis withdrawal:
• Cessation of heavy and prolonged cannabis use.
• Three or more of the following developed within 1 week of cessation:
• At least one of; abdo pain, shakiness/tremors, sweating, fever, chills, headache
1. Decreased appetite or weight-loss
2. Depressed mood
3. Irritability, anger or aggression
4. Nervousness or anxiety
5. Restlessness
6. Difficulty sleeping
• The symptoms cause clinically significant distress or impairment
• The symptoms are NOT attributable to another medical condition, mental disorder or substance.

32
Q

Describe some of the complications of cannabis use?

A

Complications of use:
• Contains high levels of carcinogens
• Similar risk for respiratory illnesses as tobacco
• Chronic use may contribute to onset or exacerbation of other mental disorders
• Concern cannabis us is a causal factor in schizophrenia and other psychotic disorders
• Cannabis use has been associated with: poor life satisfaction, increased mental health treatment and hospitalisation

33
Q

How is cannabis use disorder treated?

A

• No clearly efficacious medication treatments for cannabis use disorder
• Primary treatments: psychosocial treatments (e.g. CBT, relapse prevention programs, motivational interviewing)
Pharm:
- High potentcy antipsychotics (e.g. Haloperidol) for psychosis and agitation
- Benzodiazepines (e.g. Diazepam) is recommended to treat agitation in the absence of psychosis

Psychiatry (6 decks)

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