Flashcards in Substance Abuse/Addictive Deck (79):
How long can amphetamines be detected on UDS for?
1-3 days, but LOW Se/Sp
How long can cocaine be detected on UDS for?
How long can PCP be detected on UDS for?
How long can opioids be detected on UDS for?
How long can THC/cannabinoids be detected on UDS for?
3days - 4weeks (released from adipose stores)
How long can barbiturates be detected on UDS for? Specifically pentobarbital vs phenobarbital?
PENTObarbital = short-acting - 24hrs
PHENObarbital = long-acting - 3wks
How long can benzodiazepines be detected on UDS for? Specifically lorazepam vs diazepam
Lorazepam = short-acting - 5days
Diazepam = long-acting - 30days
ALCOHOL: What are the supposed mechanisms of EtOH?
ACTIVATES GABA, dopamine, 5-HT/Ser
INHIBITS GLU, voltage-gated Ca
ALCOHOL: What are the components of a CIWA protocol?
ALCOHOL: What is the short-term treatment for EtOH withdrawal?
BZ taper - CHLORDIAZEPOXIDE (librium), LORAZEPAM (Ativan) moreso than DIAZEPAM (Valium - Longer acting)
ALCOHOL: What is the course of EtOH withdrawal sx?
Onset: 6hrs and can last up to 2-7days
1) Generalized tonic clonic seizures (GTC) - 12-48hrs, peaks at 12-24hrs
2) Delirium tremens (DT) only occurs in 5% of population - have associated sx, peaks at 48-96hrs
ALCOHOL: What electrolyte abnormality predisposes to alcohol withdrawal-related GTCs?
ALCOHOL: What are the 3 risk factors that predisposes to alcohol withdrawal-related DTs?
Medical illness, age>30yo, prior DT
ALCOHOL: What is in the BANANA BAG for actively withdrawing from alcohol pts?
THIAMINE/VIT B1 + FOLATE + MULTIVITAMIN
Mainly to prevent Wernicke's
ALCOHOL: What are the 2 1ST LINE MEDICATIONS used for LONG-TERM ALCOHOL USE DISORDER?
1) NALTREXONE (Oral Revia, IM-Vivitrol) - ACTIVELY drinking
2) ACAMPROSATE (Campral) - ABSTINENT maintenance
ALCOHOL: 1st LINE: How does NALTREXONE work for ALCOHOL USE DISORDER? Contra-indicated in which pts?
Opioid antagonist that decreases "cravings" or the "high" associated with EtOH
Contra-indicated in pts w/ physiologic dependence to opioids + ACUTE LIVER FAILURE/hepatitis
ALCOHOL: 1st LINE :How does ACAMPROSATE work for ALCOHOL USE DISORDER? Can it be used in pts with severe liver dz or severe renal dz?
Modulates (Decreases) GABA transmission - Started POST-DETOX to prevent relapses?
YES, can be used for LIVER Dz
NO, can NOT be used for RENAL Dz pts
ALCOHOL: What are the 2 2ND LINE MEDICATIONS used for LONG-TERM ALCOHOL USE DISORDER?
1) DISULFURAM (Antabuse)
2) TOPIRAMATE (Topamax)
ALCOHOL: 2nd LINE: How does DISULFURAM work for ALCOHOL USE DISORDER? Contra-indications?
Blocks ALDEHYDE DEHYDROGENASE in liver -> Causes aversive rxn to EtOH (flushing/HA/N/V/palpitations/SOB)
CONTRA-INDICATIONS: Pregnancy + Psychosis + Severe cardiac dz
ALCOHOL: 2nd LINE: How does TOPIRAMATE work for ALCOHOL USE DISORDER?
Potentiates GABA, Inhibits Glu -> Reduces cravings and decreases EtOH use
ALCOHOL: In managing alcohol withdrawal pts with altered mental status (AMS), what is critical about the order of treatment?
Give THIAMINE/VITB1 BEFORE Glc infusion
If Glc is given first, will precipitate Wernicke-Korsakoff encephelopathy bec any limited VitB1 leftover will immediately be utilized with Glc by carbohydrate metabolism -> Acute neuronal damage
ALCOHOL: What are the 2 LONG-TERM COMPLICATIONS of ALCOHOL USE DISORDER?
1) WERNICKE ENCEPHELOPATHY - Confusion + Broad-based ataxia + Ophthalmoplegia (horizontal nystagmus, gaze palsy)
2) KORSAKOFF SYNDROME - Impaired recent memory + Chronic amnesia, anterograde amnesia + Compensatory confabulation
ALCOHOL: What is the cause of Wernicke Encephalopathy? Is this reversible?
ALCOHOLISM -> Decreased nutrition -> DECREASED VITB1/THIAMINE
YES, Reversible with VITB1 therapy
ALCOHOL: Is Korsakoff syndrome reversible?
Reversible in only 20% of patients
COCAINE: What is the mechanism of Cocaine?
BLOCKS presynaptic-reuptake of NE/E, DOPAMINE -> Increases Neurotransmitters in cleft "reward" system
COCAINE: How can cocaine use be lethal?
VASOCONSTRICTIVE effect-mediated MI, ICH, STROKE
Respiratory depression/arrhythmia, Tactile hallucinations
COCAINE: What is the mgmt of a cocaine user pt?
1) MILD-MOD Agitation - Reasurrance + BZ
2) SEVERE Agitation - Haloperidol
3) Monitor VS, HTN, arrhythmia
4) If Temp>102, AGGRESSIVE - Cooling blanket + ice bath + supportive measures
COCAINE: Is abrupt abstinence and withdrawal lethal?
Common pinpoint sx of cocaine withdrawal?
NO, withdrawal is not life-threatening
CONSTRICTED PUPILS (PNS), CRASH/DEPRESSION/INCREASED SI + Hyperphagia + increased dreamings
AMPHETAMINES: What is the mechanism of amphetamines?
Blocks re-uptake + facilitates release of NE + DOPAMINE
AMPHETAMINES: What are the examples of amphetamines?
METHYAMPHETAMINE (Desoxyn, "ice, speed, crystal meth, crank")
AMPHETAMINES: What are the examples of substituted "designer/club drugs" amphetamines? Mechanism?
MDMA (ECSTASY) + MDEA (EVE)
Releases NE + DOPAMINE +5-HT/SER
AMPHETAMINES: When ECSTASY/MDMA are combined with SSRIs, what can happen?
AMPHETAMINES: Sx of overdose
DILATED PUPILS + euphoria/increased libido, tachy/perspirations, grinding teeth, chest pain, hyperthermia, dehydration, rhabdo, renal failure
CHRONIC methamphetamine use - TOOTH DECAY/POOR DENTITION "meth mouth" + TACTILE HALLUCINATIONS/ PARANOIA/ EXCORIATIONS due to skin picking
MDMA/MDEA - Induces sense of closeness
PCP: What is the mechanism of PCP?
PCP = angel dust = stimulant or depressant (dependent on dose)
Antagonizes NMDA Glu-R + Activates dopaminergic neurons
PCP: Which drug is similar to PCP, but less potent - odorless/tasteless/date rape drug - tachy/tachypnea/hallucinations + amnesia?
PCP: What is the cardinal symptom of PCP intoxication?
NYSTAGMUS (**rotatory, horizontal, or vertical)
Which two substances can produce both TACTILE + VISUAL HALLUCINATIONS?
COCAINE + PCP
PCP: What is the treatment of PCP INTOXICATION?
1) Control environment - minimize sensory stimulation
2) Monitor VS, temperature, electrolytes
3) Agitation/anxiety/muscle spasms/seizures - Use BZ (lorazepam)
4) Severe agitation/psychosis - Use antipsychotics haloperidol
Intoxication of which drug is most likely to result in violence?
SED/HYPNOTIC: Which drug is a dose-specific CNS depressant that produces confusion/dizziness/drowsiness/memory loss + respiratory depression/coma commonly used as a date rape drug?
GAMMA HYDROXYBUTYRATE (GHB)
SED/HYPNOTIC: What is the mechanism of BZ? What is the mechanism of BARBITURATES?
BOTH potentiate GABA effects.
BZ: Modulate GABA-R -> Increases FREQUENCY of Cl- channel opening
BARBITURATES: Binds GABA-R -> Increases DURATION of Cl- channel opening
SED/HYPNOTIC: Why do BARBITURATES have a lower margin of safety than BZ?
AT HIGH DOSES: Barbiturates can act as DIRECT GABA AGONISTS
Synergistic in combination with other CNS depressants - BZ, EtOH, opioids, narcotics -> can result in respiratory depression
SED/HYPNOTIC: Of all kinds of drug withdrawals, which withdrawal has the highest mortality rate?
SED/HYPNOTIC: What is the REVERSAL AGENT for BZ OVERDOSE? Mechanism? Used with caution bec it may precipitate __?
FLUMAZENIL = Short acting BZ antagonist
May precipitate seizures
SED/HYPNOTIC: What is the REVERSAL AGENT for BARBITURATE OVERDOSE? Mechanism?
SODIUM BICARBONATE = Alkalinize urine to promote renal excretion of barbiturates
SED/HYPNOTIC: If BZ/barbiturates are ingested within 4-6hrs, what can be done?
ACTIVATED CHARCOAL, GASTRIC LAVAGE - Prevent further GI absorption
SED/HYPNOTIC: Is withdrawal from chronic BZ/BARBITURATE use life-threatening?
YES, life-threatening - GTC SEIZURES** (same as EtOH withdrawal)
BARBITURATE withdrawal has the highest mortality rate
Rule of thumb for life-threatening withdrawal from substances
Withdrawal from DEPRESSANTS (EtOH, BZ, Barbiturates) = Life-threatening
Withdrawal from STIMULANTS (cocaine, amphetamines, PCP) = NOT life-threatening
OPIOIDS: What is the mechanism of opioids?
1) STIMULATE MU, KAPPA, DELTA opiate receptors - normally stimulated by endogenous opiates
2) DOPAMINERGIC system - mediates addictive/rewarding paths
OPIOIDS: Name the common opioids.
HEROIN, OXYCODONE, CODEINE, DEXTROMETHORPHAN (cough syrup), MORPHINE, METHADONE, MEPERIDINE (demerol)
OPIOIDS: What is a common cause of morbidity from street heroin use?
INFECTION SECONDARY TO NEEDLE SHARING
OPIOIDS: Intoxication symptoms, CLASSIC TRIAD?
MIOSIS (CONSTRICTED) + CONSTIPATION + N/V + RESPIRATORY DEPRESSION
CLASSIC TRIAD: AMS + MIOSIS + Respiratory depression
OPIOIDS: Which opioid is the only exception to producing MIOSIS?
DEMEROL DILATES PUPILS
OPIOIDS: Which opioid taken with MAO inhibitors can cause SER SYNDROME?
MEPERIDINE + MAO-I can cause SER SYNDROME
OPIOIDS: What is the agent used for OPIOID OVERDOSE?
NALOXONE - opioid antagonist
Will improve respiratory depression but can cause SEVERE WITHDRAWAL in opioid-dependent pt
OPIOIDS: Cardinal sx for opioid withdrawal
DILATED PUPILS + RHINORRHEA/LACRIMATION/YAWNING + Piloerection + ARTHRALGIA/MYALGIA + abdominal cramping + Hyperactive bowel sounds
OPIOIDS: What in the diet can give a false positive for opioids in UDS?
Large amts of poppy seed bagels/muffins
OPIOIDS: What is the gold-standard treatment for pregnant opioid-dependent women? What is its mechanism of action?
METHADONE - LONG-ACTING opioid-R antagonist
OPIOIDS: Adverse components of METHADONE
QTc prolongation, caution with cardiac dz pts
Only federally licensed substance abuse programs can dispense
OPIOIDS: Which is a safer alternative for OPIOID DEPENDENCE than methadone due to "ceiling effect"? Mechanism of action?
BUPRENORPHINE - partial opioid-R agonist
Effects reach a plateau -> Make overdose unlikely
OPIOIDS: What is the preparation of SUBUTEX and SUBOXONE?
SUBUTEX - Sublingual buprenorphine
SUBOXONE - Sublingual buprenorphine/naloxone
OPIOIDS: What is the purpose of naloxone in SUBOXONE?
Naloxone only acts as a DETERRENT if pt tries to inject suboxone
BUPRENORPHINE = fat-soluble = sole molecule in suboxone responsible for diminishing cravings
NALOXONE = water-soluble = normally no action if used properly; if injected, will precipitate withdrawal
OPIOIDS: Other than methadone and buprenorphine, what is another pharmacological treatment of opioid use disorder? Mechanism of action?
NALTREXONE - Oral daily OR IM depot injection monthly
Competitive opioid antagonist - will precipitate withdrawal if used within 7d of heroin usage
OPIOIDS: What is the biggest hindrance for subscribing NALTREXONE for opioid use disorder?
COMPLIANCE - Have to take daily or monthly injection
OPIOIDS: Is withdrawal from opioids life-threatening?
NOT life-threatening, but does show severe symptoms - anxiety/anorexia + insomnia/fever/rhinorrhea/piloerection
OPIOIDS: What is the management of OPIOID OVERDOSE?
1) Moderate sx - symptomatic tx: Pain - NSAIDs, abdominal cramps - dicyclomine, autonomic signs/withdrawal - clonidine
2) Severe sx - detox with buprenorphine/methadone
HALLUCINOGEN: What are the common hallucinogens? Proposed mechanism of action?
PSILOCYBIN (MUSHROOMS), MESCALINE (PEYOTE CACTUS), LSD
Acts on 5-HT/serotonergic system
HALLUCINOGEN: Cardinal sx of halucinogen overdose
LSD flashback - recurrence of symptoms mimicking prior LSD trip that occurs spontaneously and lasts for mins-hrs
MARIJUANA: What is the most common active component in marijuana? Mechanism of action?
THC = most common active component
Cannabinoid-R in brain inhibit adenylate cyclase
MARIJUANA: Medical conditions treated by THC
1) N/V in chemotherapy pts
2) Decreases pain from cancer pts
3) Increases appetite in AIDS
4) Decreases IOP in glaucoma pts
MARIJUANA: What is the pill form of THC that is FDA-approved for certain indications?
NICOTINE: What is the supposed mechanism of action of nicotine?
NICOTINE stimulates nicotinic-R in autonomic ganglia of SNS and PNS + effects on dopaminergic system
NICOTINE: What are 2 FDA-approved pharmacotherapy for nicotine dependence?
1) VARENICLINE - alpha4beta2 cholinergic receptor partial agonist mimics action of nicotine - reduces awarding aspects + prevents withdrawal
2) BUPROPION - antidepressant NET, DAT inhibitor
SED/HYPNOTIC: What are signs of BZ ONLY overdose? At what point do you think of co-ingestion of another hypnotic/sedative?
ALTERED LOC + SLURRED SPEECH + ATAXIA = BZ only
VS alteration (hypotension, bradycardia, decreased respiratory rate) = BZ + ETOH (most common co-ingested)
INCREASED AGGRESSION + MALE PATTERN BALDNESS (receding hair line) + GYNECOMASTIA + DECREASED TESTICULAR SIZE/SPERM COUNT/VIRILIZATION + ACNE + DECREASED HDL + HEPATIC DYSFUNCTION = abuse of __?
ANABOLIC STEROIDS (testosterone)
ALCOHOL: Which BZ should NOT be used in pts undergoing EtOH Withdrawal with suspected liver disease? Which is safer for liver disease pts?
CHLORDIAZEPOXIDE (Librium) is NOT used
LORAZEPAM (Ativan) is SAFER
Which ELECTROLYTE abnormality is common with MDMA (ECSTASY) INTOXICATION?
HYPONATREMIA -> Can result in COMA/DEATH/SEIZURES
Which amphetamines can NOT be detected on UDS? What can give false positives?
FALSE +: BUPROPRION, DECONGESTANT (PSEUDOPHEDRINE), SELEGILINE