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Flashcards in Substance Abuse/Addictive Deck (79):
1

How long can amphetamines be detected on UDS for?

1-3 days, but LOW Se/Sp

2

How long can cocaine be detected on UDS for?

2-4 days

3

How long can PCP be detected on UDS for?

4-7 days

4

How long can opioids be detected on UDS for?

1-3 days

5

How long can THC/cannabinoids be detected on UDS for?

3days - 4weeks (released from adipose stores)

6

How long can barbiturates be detected on UDS for? Specifically pentobarbital vs phenobarbital?

PENTObarbital = short-acting - 24hrs
PHENObarbital = long-acting - 3wks

7

How long can benzodiazepines be detected on UDS for? Specifically lorazepam vs diazepam

Lorazepam = short-acting - 5days
Diazepam = long-acting - 30days

8

ALCOHOL: What are the supposed mechanisms of EtOH?

ACTIVATES GABA, dopamine, 5-HT/Ser
INHIBITS GLU, voltage-gated Ca

9

ALCOHOL: What are the components of a CIWA protocol?

ANXIETY/AGITATION
AH/VH/TH (formication)
HA/ORIENTATION
TREMOR/PAROXYSMAL SWEATS
N/V

10

ALCOHOL: What is the short-term treatment for EtOH withdrawal?

BZ taper - CHLORDIAZEPOXIDE (librium), LORAZEPAM (Ativan) moreso than DIAZEPAM (Valium - Longer acting)

11

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

12

ALCOHOL: What electrolyte abnormality predisposes to alcohol withdrawal-related GTCs?

HYPOMAGNESIUM

13

ALCOHOL: What are the 3 risk factors that predisposes to alcohol withdrawal-related DTs?

Medical illness, age>30yo, prior DT

14

ALCOHOL: What is in the BANANA BAG for actively withdrawing from alcohol pts?

THIAMINE/VIT B1 + FOLATE + MULTIVITAMIN
Mainly to prevent Wernicke's

15

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

16

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

17

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

18

ALCOHOL: What are the 2 2ND LINE MEDICATIONS used for LONG-TERM ALCOHOL USE DISORDER?

1) DISULFURAM (Antabuse)
2) TOPIRAMATE (Topamax)

19

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

20

ALCOHOL: 2nd LINE: How does TOPIRAMATE work for ALCOHOL USE DISORDER?

Potentiates GABA, Inhibits Glu -> Reduces cravings and decreases EtOH use

21

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

22

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

23

ALCOHOL: What is the cause of Wernicke Encephalopathy? Is this reversible?

ALCOHOLISM -> Decreased nutrition -> DECREASED VITB1/THIAMINE

YES, Reversible with VITB1 therapy

24

ALCOHOL: Is Korsakoff syndrome reversible?

MORESO IRREVERSIBLE
Reversible in only 20% of patients

25

COCAINE: What is the mechanism of Cocaine?

BLOCKS presynaptic-reuptake of NE/E, DOPAMINE -> Increases Neurotransmitters in cleft "reward" system

26

COCAINE: How can cocaine use be lethal?

VASOCONSTRICTIVE effect-mediated MI, ICH, STROKE

Respiratory depression/arrhythmia, Tactile hallucinations

27

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

28

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

29

AMPHETAMINES: What is the mechanism of amphetamines?

Blocks re-uptake + facilitates release of NE + DOPAMINE

30

AMPHETAMINES: What are the examples of amphetamines?

DEXTROAMPHETAMINE (Dexedrine)
METHYLPHENIDATE (Ritalin)
METHYAMPHETAMINE (Desoxyn, "ice, speed, crystal meth, crank")

31

AMPHETAMINES: What are the examples of substituted "designer/club drugs" amphetamines? Mechanism?

MDMA (ECSTASY) + MDEA (EVE)
Releases NE + DOPAMINE +5-HT/SER

32

AMPHETAMINES: When ECSTASY/MDMA are combined with SSRIs, what can happen?

SER SYNDROME

33

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

34

PCP: What is the mechanism of PCP?

PCP = angel dust = stimulant or depressant (dependent on dose)
Antagonizes NMDA Glu-R + Activates dopaminergic neurons

35

PCP: Which drug is similar to PCP, but less potent - odorless/tasteless/date rape drug - tachy/tachypnea/hallucinations + amnesia?

KETAMINE

36

PCP: What is the cardinal symptom of PCP intoxication?

NYSTAGMUS (**rotatory, horizontal, or vertical)
+ VIOLENCE/DELIRIUM/dissociation/ataxia

37

Which two substances can produce both TACTILE + VISUAL HALLUCINATIONS?

COCAINE + PCP

38

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

39

Intoxication of which drug is most likely to result in violence?

PCP

40

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)

41

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

42

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

43

SED/HYPNOTIC: Of all kinds of drug withdrawals, which withdrawal has the highest mortality rate?

BARBITURATE WITHDRAWAL

44

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

45

SED/HYPNOTIC: What is the REVERSAL AGENT for BARBITURATE OVERDOSE? Mechanism?

SODIUM BICARBONATE = Alkalinize urine to promote renal excretion of barbiturates

46

SED/HYPNOTIC: If BZ/barbiturates are ingested within 4-6hrs, what can be done?

ACTIVATED CHARCOAL, GASTRIC LAVAGE - Prevent further GI absorption

47

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

48

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

49

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

50

OPIOIDS: Name the common opioids.

HEROIN, OXYCODONE, CODEINE, DEXTROMETHORPHAN (cough syrup), MORPHINE, METHADONE, MEPERIDINE (demerol)

51

OPIOIDS: What is a common cause of morbidity from street heroin use?

INFECTION SECONDARY TO NEEDLE SHARING

52

OPIOIDS: Intoxication symptoms, CLASSIC TRIAD?

MIOSIS (CONSTRICTED) + CONSTIPATION + N/V + RESPIRATORY DEPRESSION
CLASSIC TRIAD: AMS + MIOSIS + Respiratory depression

53

OPIOIDS: Which opioid is the only exception to producing MIOSIS?

DEMEROL DILATES PUPILS
DEMEROL/mepiridine

54

OPIOIDS: Which opioid taken with MAO inhibitors can cause SER SYNDROME?

MEPERIDINE + MAO-I can cause SER SYNDROME

55

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

56

OPIOIDS: Cardinal sx for opioid withdrawal

DILATED PUPILS + RHINORRHEA/LACRIMATION/YAWNING + Piloerection + ARTHRALGIA/MYALGIA + abdominal cramping + Hyperactive bowel sounds

57

OPIOIDS: What in the diet can give a false positive for opioids in UDS?

Large amts of poppy seed bagels/muffins

58

OPIOIDS: What is the gold-standard treatment for pregnant opioid-dependent women? What is its mechanism of action?

METHADONE - LONG-ACTING opioid-R antagonist

59

OPIOIDS: Adverse components of METHADONE

Can OD
QTc prolongation, caution with cardiac dz pts
Only federally licensed substance abuse programs can dispense

60

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

61

OPIOIDS: What is the preparation of SUBUTEX and SUBOXONE?

SUBUTEX - Sublingual buprenorphine
SUBOXONE - Sublingual buprenorphine/naloxone

62

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

63

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

64

OPIOIDS: What is the biggest hindrance for subscribing NALTREXONE for opioid use disorder?

COMPLIANCE - Have to take daily or monthly injection

65

OPIOIDS: Is withdrawal from opioids life-threatening?

NOT life-threatening, but does show severe symptoms - anxiety/anorexia + insomnia/fever/rhinorrhea/piloerection

66

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

67

HALLUCINOGEN: What are the common hallucinogens? Proposed mechanism of action?

PSILOCYBIN (MUSHROOMS), MESCALINE (PEYOTE CACTUS), LSD
Acts on 5-HT/serotonergic system

68

HALLUCINOGEN: Cardinal sx of halucinogen overdose

LSD flashback - recurrence of symptoms mimicking prior LSD trip that occurs spontaneously and lasts for mins-hrs

69

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

70

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

71

MARIJUANA: What is the pill form of THC that is FDA-approved for certain indications?

DRONABINOL

72

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

73

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

74

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)

75

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)

76

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

77

Which ELECTROLYTE abnormality is common with MDMA (ECSTASY) INTOXICATION?

HYPONATREMIA -> Can result in COMA/DEATH/SEIZURES

78

Which amphetamines can NOT be detected on UDS? What can give false positives?

BATH SALTS
FALSE +: BUPROPRION, DECONGESTANT (PSEUDOPHEDRINE), SELEGILINE

79

ANTICHOLINERGIC TOXICITY and AMPHETAMINE intoxication both present with tachy, htn, mydriasis. How do you differentiate between the two?

ANTICHOLINERGIC TOXICITY: Dry as a bone - dry skin/mucous membranes, + MOTOR sx (Myoclonic jerks, tremors), Delirium rather than psychosis +Other sx (ileus, urinary retention)

AMPHETATMINE INTOXICATION: Diaphoretic/profuse sweating, - Motor Sx, Isolated psychosis sx