Flashcards in Substance abuse-test 2 Deck (112):
What is substance abuse?
A chronic disorder characterized by the compulsive use of substance resulting in physical, psychological, or social harm to be user and continued use despite the harm.
What is substance intoxication?
Reversible substance-specific syndrome
nDue to recent ingestion or exposure to a substance
Clinically significant maladaptive behavior or psychological changed due to the effect of the substance on the CNS
What are the key components of the pathways activated by abused substances?
DA in mesocorticolimbic system
Nucleus Accumbens (NA) to prefrontal cortex, amygdala and olfactory tubule.
What do cocaine and other stimulants block?
What do opiods affect?
Activate u receptors resulting in increased release of DA in NA
Where does nicotine act?
It acts with the opiod pathway
What does the active ingredient of marijuana ( THC) work in the pathway?
binds to cannabinoid-1 (CB1) receptors resulting in activation of DA neurons in mesolimbic system
What does chronic use lead to?
General decrease in DA neurotransmission
What are the 2 explanations for the dev of substance dependence?
What is sensitization?
Increased response following repeated intermittent administration of a drug, in contrast to tolerance to drug effects that occur secondary to continuous exposure to a drug
What is counteradaptation?
Initial positive reward feeling followed by the opposing development of tolerance
What 10 drug classes are encompassed in criterion A for DSM V diagnosis of substance abuse?
Alcohol, caffeine, hallucinogens, inhalants, opioids, sedatives, hypnotics, stimulants, and anxiolytics
What are the categories for symptoms?
What are the qualifications of impaired control?
1.Take substance in large amounts or over longer period than originally intended
2.Individual may express persistent desire to cut down or regulate use and may report unsuccessful attempts
3.Individual may spend a great deal of time obtaining substance, using the substance, or recovering from the effects
4.Craving is manifested by an intense desire or urge for the drug that may occur at any time but is more likely in an environment where the drug was previously obtained
What constitutes social impairment?
1.Failure to fulfill major role obligations at work, school, or home
2.Continue substance abuse despite having persistent or recurrent social or interpersonal problems caused or exaggerated by the effects of the substance
3.Important social, occupational, or recreational activities may be given up or reduced because of substance abuse
What constitutes risky use?
1.Recurrent use in situations in which it is physically hazardous
2.Continue to use despite having knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by the substance
What is the criteria for tolerance?
signaled by requiring a markedly increased dose to achieve the desired effect
What is the criteria for withdrawal?
The development of a substance-specific syndrome due to the cessation use that has been heavy and prolonged.
What does the substance-specific syndrome cause?
clinically significant distress or impairment in social, occupational, or other important areas of functioning.
What is severity rating for abuse?
-2-3 of the above symptoms
-4-5 of the above symptoms
-6 or more of the above symptoms
What is alcohol? How does it work?
Works in a dose dependent fashion: Sedative, sleep, unconsciousness, coma, respiratory depression and CV collapse
What does alcohol affect in the brain?
GABA, glutamate and dopamine
Affects endogenous opioids (release)
What is the definition of current use?
at least one drink in the past 30 days (includes binge and heavy use)
What is the definition of binge use?
five or more drinks on the same occasion at least once in the past 30 days
What is the definition of heavy use?
five or more drinks on the same occasion on at least 5 different days in the past 30 days.
What is glutamate?
Major excitatory system in CNS
What is the NMDA receptor responsible for when activated?
What affect does acute ethanol intoxication have on the NMDA receptors?
Inhibits, decreasing glutamate activity
This is the sedative, incoordinating, amnestic, and anxiolytic effect of alchol
What affect does chronic ethanol intoxication have on the NMDA receptors?
Causes an upregulation of NMDA receptor number and function leading to hypersensitivity
What is GABA?
Major inhibitory system in CNS
What are the 2 principle receptor subtypes of GABA?
GABAA receptor subtypes
GABAA R activation→ inhibition
What is the effect of acute ethanol intoxication on GABA?
Potentiates GABAA inhibition
Sedative, incoordinating, amnestic, and anxiolytic effects of alcohol
What is the effect of chronic ethanol intoxication on GABA?
Down-regulation of GABAA R number and function
What happens with DA and ethanol?
Ethanol activates mesolimbic DA systems→
increases DA release in nucleus accumbens (NAc)
Positive reinforcement and pleasurable effects of ethanol
What is mild- mod intoxication? What are the s/s ?
BAL 0.08 to 0.1%
Lower limits of legal intoxication
Do not require formal treatment
Mood labilty, loud or inappropriate behavior, slurred speech, incoordination, unsteady gait
What is severe intoxication and s.s?
(BAL 0.2-0.3%) confusion, depressed consciousness, vomiting
(BAL 0.3-0.4%) stupor, coma
(BAL > 0.4%) cardiac arrhythmias, respiratory depression, death
What should be given if your pt has impaired consciousness?
thiamine should be given IV or IM for at least 3 days
how many yes need to happen in the CAGE questionnaire in order to be considered positive?
What does CAGE stand for?
What drugs can be used to tx alcohol dependence?
What is the disulfiram ethanol reaction?
What is the dosing for disulfiram?
Range from 125-500mg/d
Start when abstinent from ETOH for at least 12 hours
How long does it take to get the full “protective” effect of disulfiram?
How long of a washout do you need before there can be alcohol interaction?
What are predictors of success with disulfiram?
High risk situations (e.g. weddings) where behavior is important
Contingencies (e.g. loss of license)
Stable home life
What is naltrexone approved for?
Narcotic abuse and alcohol dependence
What is the MOA of naltrexone and alcohol dependence?
Competitive mu (µ) opioid receptor antagonist
Naltrexone blocks ß- endorphin which stimulates dopamine release
Naltrexone blocks ethanol- induced DA release in NAC
What is the effect of natrxone and alcohol abuse?
Not really that great
What is acamprosate approved for?
To maintain abstinence after detox
What is the MOA of acamprosate?
“restores balance” between glutamate and GABA
May ↓ glutamate overactivity
May ↓ ability of ethanol to activate mesolimbic dopamine system
How effective is acamprosate?
Moderate effects at best
Similar decreases in drinking frequency, and similar relapse rates as naltrexone
What are the ADRs of acamprosate?
Only ADR reported in > 10% patients and at a rate > placebo was transient diarrhea
When does acamprosate need to be dose adjusted or when is it CI?
Should not be used if CCI
What other meds is acamprosate safe to use with?
What are minor alcohol withdrawal symptoms?
Vital signs increase (mild)
What is the time course for minor withdrawal?
Onset: 8-12 Hours
Peak: 24-36 Hours
Duration: 60-72 hours
What are the s/s of major withdrawal?
Delirium Tremems: (DT’s)
Vital signs increased (Marked)
What is the time course for major withdrawal symptoms?
Onset: 48-60 hours
Peak: 72 hours
Duration: 120-168 hours
What CIWA-Ar scoring for pharm therapy?
What is the DOC for uncomplicated alcohol withdrawl?
Should you tx a pt with no symptoms?
What is the monitoring for pts when tx?
Monitoring patient every 4-8 h
CIWA-Ar until score has been
When CIWA-Ar is >/= 8 what should you do?
Administer 1 of the following medications every hour
Chlordiazepoxide 50-100 mg
Diazepam 10-20 mg
Lorazepam 2-4 mg
** Repeat CIWA-Ar 1 after every dose to assess need to further medication
What are the preferred bdz for alcohol withdrawal?
What are the preferred bdz for tx alcohol withdrawal in severe liver dz?
What is the tx for alcohol withdrawal in a pt that is vomiting or NPO?
Chlordiazepoxide 50mg PO = lorazepam 2-4mg IM
Supplement with lorazepam 2-4mg IM q1h for breakthrough signs/symptoms
What is the DOC in seizures associated with alcohol withdrawal?
1)Benzodiazepines drug of choice
IV diazepam 5-10mg may repeat q 5min till termination seizure
IM lorazepam 4mg
2)Correction of Electrolyte Imbalances
IV magnesium 1g q hours for 1st day
IV thiamine (as in intoxication)
How should delirium tremens be tx?
IV Benzos ‘till light somnolence is achieved
Haloperidol- given only for severe agitation unresponsive to benzos
How are the BDZ tapered depending on length of tx?
If therapy > 8 weeks, 2-3 week taper is recommended
If therapy > 6 months, 4-8 week taper should be used
If therapy > 1 year, Strong consideration should be given to using long-acting agents (Diazepam, Clonazepam)
What is the simple taper for BDZ?
25% dose reduction per week until 50% of original dose is reached
Then decrease dose by 1/8 every 4-7 days
What can happen if BDZ are suddenly dc?
Recurrence or relapse of symptoms
Short-acting agents ~ 1-2 days
Longer-acting agents ~ 2-4 days
What are common BDZ withdrawal symptoms?
What are rare BDZ withdrawal symptoms?
What are less frequent BDZ symptoms?
- Blurred vision
What are risk factors for BDZ withdrawal?
High BDZ doses
Long duration of therapy
Concurrent meds/drugs that lower seizure threshold
What are s/s of stimulant intoxication?
Tachycardia/elevated blood pressure
Sweating and/or chills
Nausea, vomiting, diarrhea
What are signs of stimulant abuse?
-Dilated pupils (high dose)
- Dry mouth
- Bad breath
- Frequent lip licking
- Decreased appetite and sleep
- Irritable, argumentative
- Talkative but tangential
- Runny/bloody nose
What problems need to be tx in stimulant intoxication?
Treat and monitor medical problems
Hyperthermia, Hypertension, Cardiac arrhythmias, Stroke
Benzodiazepines for anxiety
History and drug screen 1st because often used in combo with ethanol, opioids so benzos can increase sedation and respiratory depression
How can stimulant dependence be tx?
Therapy, groups, etc 12 step program
No proven pharmacotherapy, Disulfiram shows some promise with cocaine
What does stimulant withdrawal often lead to?
to depressed or dysphoric mood
What may be helpful in the first 24 hours of stimulant withdrawal?
benzodiazepines or antipsychotics might be helpful for delusions, paranoia, compulsive behavior
What are life-threatening complications associated with stimulant withdrawal?
Ischemic chest pain
What are s/s of opioid intoxication?
What are s/s of opioid withdrawal?
What is tx for opioid intoxication?
Reverse intoxication with naloxone 0.4-2mg IV q 2-3 min up to 10mg
How can you tx opioid dependence?
What do opioids inhibit? What does chronic use discontinuation lead to?
inhibit cyclic AMP system
Leads to cyclic AMP in the adrenergic neurons becomes overactive
Noradrenergic brain activity increases
Contributes to withdrawal symptoms
What are s/s of grade I or mild opioid withdrawal?
What are s/s of grade 2 or moderate opioid withdrawal?
What are s/s of grade 3 or marked opioid withdrawal?
Vital Signs ↑
What are s/s of grade 4 or severe opioid withdrawal?
What is clonidine? What is it used for?
Alpha adrenergic autoreceptors
Heroin: 10 day treatment
Methadone: 14 day treatment
----Clonidine taper in both cases
What is the methadone dosing for opioid withdrawal?
Initial Dose (Max=40mg/d)
Grade I: 5mg q12h
Grade II: 10mg q12h
Grade III: 15mg q12h
Grade IV: 20mg q12h
What need to be taken before each dose of methadone?
Vital signs before each dose
Titration: ↑ 5-10mg QOD as tolerated
Dose range: 30-100mg/d
What dose can you give of methadone for breakthrough s/s?
What is the MOA of methadone?
µ and ō opioid withdrawal agonist
Suppresses opioid withdrawal symptoms
Blocks effect of other opioids
What are the side effects of methadone?
Constipation, sweating, urinary retention
Respiratory depression in intolerant individuals
What is the starting dose for buprenorphine?
4mg (4/1) followed in 3-4 hrs with another 4mg (4/1mg) if indicated
2nd day 12-16mg/d (12/3-16/4mg/d) administered
What is the MOA of buprenorphine?
µ receptor partial agonist and weak K receptor antagonist
Similar effects as methadone
Opioid antagonist at higher doses
What can buprenorphine help with?
Controls cravings: Still some sense of euphoria
Safer than heroin: Not as addictive, little risk of overdose
Can be prescribed in physician office by specially trained physicians
What is the recommended dose of naltrexone?
100mg MW + 150mg F
When can naltrexone be initiated?
Once patient is opioid free for 7-10d
What does nicotine affect in the brain?
DA, NE, 5-HT, glutamate, GABA, and endogenous opioid peptides
Activates nicotinic acetylcholine receptors in the brain
What do you use to assess nicotine dependence?
Fagerström Test (score >/= 4 indicates physical dependence)
What are nicotine replacement therapies?
What are some pharm options for smoking cessation assistance?
What is the MOA of buproprion?
Blocks reuptake of DA and NE
Acts as a noncompetitive antagonist on Ach receptor
Reduces nicotine reinforcement, withdrawal, and craving
Whan can buproprion be initiated?
1-2 weeks before quit date
What is the MOA of varenicline?
agonizes and blocks nicotinic acetylcholine receptors
How soon before taking this does the pt need to quit smoking?
After 7 days of tx they need to stop
What is the BBW for varencline?
Neuropsychiatric Symptoms and Suicidality
**Weigh varenicline risks vs. benefits of smoking cessation