Substance related and Addictive Disorders

Question 1

SUD Diagnosis

Answer 1

• Impaired control
• Social Impairment
• Risky use
• Tolerance/Withdrawal
• Mild: 2-3 symptoms, Moderate: 4-5 symptoms; Severe: 6 or more symptoms
• tolerance or withdrawal not necessary for diagnosis
• Gambling, tobacco use, caffeine withdrawal, cannabis withdrawal added to DSM 5
• Suicide risk

Question 2

SUD Neuro Anatomy

Answer 2

• Mesocorticolimbic dopamine systems originating in the ventral tegemental area
• Dopamine
• Amygdala
• Withdrawal: withdrawal: significant decrease in dopamine in the nucleus accumbens

Question 3

SUD Remissions

Answer 3

• Early remission: 3 months but less then 12 months

* Sustained remission: 12 months

Question 4

AUD Screening

Answer 4

• Men more than 14 drinks/week; 4 drinks on one day
• Women more than 7 drinks/week; 3 drinks in one day
• CAGE: Cut down, Annoyed, Guilt, Eye Opener

Question 5

AUD Lab values

Answer 5

• AST/ALT elevated
• Increased MCV (macrocytic anemia): decreased HgB, B12 & Folic acid
• Carbohydrate-deficient transferrin (CDT) increased

Question 6

Alcohol Withdrawal

Answer 6

• Tremulousness, elevated BP, tachycardia, hyperthermia, N/V, Hallucinations, Seizure (7-48 hours)
• DTs (48-72 hours); autonomic hyperactivity, confusion, disorientation
• CIWA: 0-8 supportive care/monitoring; 8-14 pharmacological intervention; 15 immediate pharmacologic intervention

Question 7

Wernicke’s-Korsakoff

Answer 7

• Wernicke’s encephalopathy: Opthalmoparesis, nystagmus, ataxia, confusion
• Korsakoff: decreased short term memory, confabulation
• At risk: start parenteral thiamine 250-500 mg for 3-5 days
• Otherwise healthy prevention: oral thiamine > 300 mg/day during detoxification

Question 8

AUD Medications

Answer 8

• Benzos for withdrawal: longer half-life most effective in preventing delirium ( librium, valium)
• Disulfiram (Anatbuse): 250 mg/day, deterrent
• Acomprosate: 666 TID; reduces cravings
• Naltrexone: 50 mg qd; reduces cravings

Question 9

Stimulants

Answer 9

• Potent effect on the reward circuit pathway where dopaminergic neurons extend from the ventral tegmental area to the cerebral cortex and the limbic areas
• Intoxication: Extremes of emotion, anxiety, tachycardia or bradycardia, high or low blood pressure, psychomotor agitation or retardation, dilated pupils, confusion, seizures
• Withdrawal: Depressed mood, vivid dreams, sleep disturbance, increased appetite, psychomotor agitation/retardation
• detected in urine 1-4 days
• Treat with Benzodiazepines

Question 10

OUD Withdrawal

Answer 10

• Myalgias, lacrimation, piloerection, N/V/D
• COWS: Mild: 5-12; Moderate 13-24; Moderately Severe: 25-36; Severe: more than 36
• Treat with Buprenorphine; clonidine 0.1-0.2 mg q6
• Naltrexone: opioid agonist for maintenance

Question 11

Cannabis Withdrawal

Answer 11

• Cessation of heavy cannabis use over at least a few months
• Irritability, aggression, nervousness, anxiety, decreased appetite/weight loss
• Symptoms begin 24-48 hours; peak 4-6 days
• Motivational Enhancement Therapies (MET); CBT, Contingency management

Question 12

Caffeine

Answer 12

• Intoxication: nervousness, tachycardia, arrhythmias, psychomotor agitation
• Withdrawal: fatigue, anxiety, headache, depression, N/V

Question 13

Hallucinogens

Answer 13

• Agonistic at the post-synaptic serotonin receptors
• Dilated pupils, increased DTRs and muscle tension, increased heart rate, respiratory rate, BP
• Anxiety, depression, paranoia, depersonalization, derealization, blurred vision, ataxia

Question 14

Sedative Use

Answer 14

• Primary effect on GABA receptors
• Intoxication: Aggression, Similar to ETOH
• Withdrawal: Anxiety, dysphoria, intolerance to lights and loud noises, muscle twitching
• Flumazenil benzo receptor agonist used to reverse benzo effects