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Psychiatry clerkship > Substance-related and addictive disorders > Flashcards

Substance-related and addictive disorders Flashcards

1
Q

Criteria for substance use disorder

A

Problematic pattern of substance use that leads to impairment or distress, manifested by at least two of:

  • Using more than intended
  • Persistent desire/inability to cut down
  • Significant time spent in obtaining, using, or recovering from substance
  • Failure to fulfill obligations (work, school, etc)
  • Continued use despite social/personal probs
  • Decreased social/occupational/recreational activities
  • Use in dangerous situations (e.g. driving)
  • Continued use despite subsequent physical or psychological problem (e.g. liver disease)
  • Tolerance
  • Withdrawal
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2
Q

How can you distinguish between substance-induced vs. primary mood symptoms/disorders?

A

Primary mood symptoms persist during periods of abstinence

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3
Q

Substance use can commonly present with what psychiatric symptoms?

A

Mood symptoms and mood disorders
Psychotic symptoms
Personality disorders
Anxiety disorders

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4
Q

Define withdrawal

A

The development of a substance-specific syndrome due to cessation/reduction of substance use

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5
Q

Define tolerance

A

The need for increasing amounts of the substance to achieve the desired effect

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6
Q

How long is alcohol detectable in a patient’s system and how do you test for it?

A

Only for a few hours
Breathalyzer in the field/police
Blood testing more accurate

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7
Q

How long is cocaine detectable in a patient’s system and how do you test for it?

A

UDS stays positive for 2-4 days

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8
Q

How long are amphetamines detectable in a patient’s system and how do you test for it?

A

UDS positive for 1-3 days

Most assays are not adequate sensitivity/specificity

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9
Q

How long is phencyclidine detectable in a patient’s system and how do you test for it?

A

UDS positive 4-7days

CPK and AST are often elevated

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10
Q

How long are benzos detectable in a patient’s system and how do you test for it?

A

Short-acting (lorazepam) for up to 5 days in blood or urine

Long-acting (diazepam) for up to 30 days in blood or urine

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11
Q

How long are barbiturates detectable in a patient’s system and how do you test for it?

A 
Short acting (pentobarbital) 24 hours in urine or blood
Long-acting (phenobarbital) 3 weeks in urine or blood
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12
Q

How long are opioids detectable in a patient’s system and how do you test for it?

A

UDS positive for 1-3 days (depending on drug)

Methadone comes up negative on a general screen

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13
Q

How long is marijuana/THC detectable in a patient’s system and how do you test for it?

A

3 days after a single use. Up to 4 weeks in heavy users, because THC is released from adipose stores

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14
Q

Alcohol activates what neurotransmitters/receptors in the CNS? Which does it inhibit?

A

Activates: GABA, Dopamine, Serotonin
Inhibits: Glutamate, voltage-gated calcium channels

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15
Q

Describe the metabolism of alcohol

A

Alcohol –> acetaldehyde (by alcohol dehydrogenase)

Acetaldehyde –> acetic acid (by acetaldehyde dehydrogenase (inhibited by disulfiram))

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16
Q

Presentation of alcohol intoxication

A 
In order of increasing BALs:
Loss of fine motor control
Impaired judgment and coordination
Ataxic gait and poor balance
Lethargy, difficulty sitting upright, memory problems, nausea/vomiting
Coma (in novice drinker)
Respiratory depression and risk of death
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17
Q

Treatment of alcohol intoxication

A

Monitor: ABCs, glucose, lytes, acid-base status
Thiamine and folate
Naloxone (if opioid co-ingestion)
CT head if trauma
Liver will take care of the rest
If severely intoxicated, may need mechanical ventilation with monitoring of above variables
GI evacuation NOT indicated UNLESS significant ingestion within the last hour

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18
Q

Clinical presentation of alcohol withdrawal

A

Alcohol withdrawal syndrome: insomnia, anxiety, hand tremor, irritability, anorexia, nausea, vomiting, autonomic hyperactivity, psychomotor agitation, fever, seizures, hallucinations, delirium

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19
Q

When do the earliest symptoms of ethanol withdrawal appear?

A

6-24 hours after the patient’s last drink

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20
Q

When do seizures occur in alcohol withdrawal?

A

12-48 hours after last drink, with peak around 12-24hrs

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21
Q

What should be corrected promptly in alcohol-withdrawal patients to help prevent seizures?

A

Hypomagnesemia

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22
Q

When does delirium tremens usually begin?

A

48-96 hours after last drink, but may be later

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23
Q

What factors increase a patient’s risk for DTs?

A

Age >30, prior DTs, physical illness

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24
Q

Symptoms of DTs

A

Delirium, hallucinations (visual), agitation, gross tremor, autonomic instability, fluctuating psychomotor activity

25
Q

Treatment for alcohol withdrawl

A

Benzodiazepines
Carbamazepine and valproate in mild withdrawl
Antipsychotics, restraints for severe agitation
Thiamine, folic acid, and multivitamin
Correct lyte/fluid abnormalities
CIWA
Check for signs of trauma, liver failure

26
Q

Medications for alcohol use disorder

A

First-line: Naltrexone (opioid receptor blocker) or acamprosate (modulates glutamate transmission)
Second-line: disulfiram and topiramate

27
Q

Considerations for using disulfiram

A

Only for highly-motivated patients who will maintain abstinence and take the med
Monitor LFTs

28
Q

Considerations for using acamprosate

A

Contraindicated in patients with renal disease

Okay to use in patients with liver disease

29
Q

What are the questions on the AUDIT-C questionnaire?

A

How often did you have a drink containing alcohol in the past year?
How many drinks did you have on a typical day when you drank alcohol in the past year?
How often did you have six or more drinks on one occasion in the past year?

30
Q

What are the neurochemical effects of cocaine?

A

Blocks reuptake of dopamine, epinephrine, and norepinephrine, causing stimulant effect

31
Q

General features of cocaine intoxication

A

Euphoria, heightened self-esteem, +/- blood pressure, +/- HR, nausea, mydriasis, psychomotor agitation or depression, chills, sweating

32
Q

Dangerous features of cocaine intoxication

A

Respiratory depression, seizures, arrhythmias, hyperthermia, paranoia, hallucinations (esp tactile)

33
Q

Life-threatening effects of cocaine

A

Vasoconstriction –> MI, ICH, or stroke

34
Q

Management of cocaine intoxication

A

Mild-to-moderate: Reassurance and benzos
Severe or psychosis: antipsychotics (haldol)
Symptomatic treatment
Hyperthermia –> treat with ice bath, cooling blankets

35
Q

Treatment of cocaine use disorder

A

No FDA-approved treatments
Consider disulfiram, modafinil, topiramate
Counseling

36
Q

Features of cocaine withdrawal

A

Not life-threatening
Post-intoxication depression/crash, can become suicidal
May need hospitalization for psychiatric symptoms

37
Q

What are the neurochemical effects of amphetamines?

A

Classic amphetamines (dextroamphetamine, methylphenidate, methamphetamine) block reuptake and facilitate release of dopamine and norepinephrine

38
Q

Symptoms of amphetamine abuse

A

Euphoria, mydriasis, increased libido, tachycardia, perspiration, grinding teeth, chest pain

39
Q

Presentation of amphetamine overdose

A

Hyperthermia, dehydration, rhabdo, renal failure

40
Q

Treatment of amphetamine intoxication

A

Rehydrate, correct lytes, treat hyperthermia

41
Q

Neurochemical effects of PCP

A

NMDA antagonist, dopamine agonist

42
Q

Symptoms of PCP intoxication

A

Agitation, depersonalization, hallucinations, synesthesia, impaired judgment, memory impairment, violent behavior, nystagmus, ataxia, dysarthria, HTN, tachycardia, muscle rigidity

43
Q

PCP overdose

A

Can cause seizures, delirium, coma, death

44
Q

Treatment of PCP intoxication

A

Monitor vitals, temp, lytes
Benzos to treat agitation, anxiety, spasms, seizures
Antipsychotics to control sever agitation or psychotic symptoms

45
Q

Clinical presentation of sedative-hypnotic intoxication (benzos or barbs, etc)

A

Drowsy, confused, hypotension, slurred speech, respiratory depression, ataxia, mood lability, impaired judgment, nystagmus, respiratory depression, coma or death

Synergistic when combined with EtOH or opioids

46
Q

Treatment of sedative-hypnotic intoxication

A

ABCs, monitor vitals
Activated charcoal or gastric lavage (if ingestion in past 4-6 hrs)
Supportive care

47
Q

What should you give in benzodiazepine overdose?

A

Flumazenil (benzo receptor antagonist)

48
Q

What should you give in barbiturate overdose?

A

Alkalinize urine with NaHCO3 to promote renal excretion

49
Q

Worst withdrawal (in terms of mortality)?

A

Barbiturates

50
Q

Presentation of withdrawal from sedative-hypnotics?

A

Same presentation as EtOH withdrawal.

Tonic-clonic seizures

51
Q

Treatment of sedative-hypnotic withdrawal?

A

Benzodiazepine taper

52
Q

Clinical presentation of opioid intoxication

A

Drowsiness, nausea/vomiting, constipation, slurred speech, miosis, seizures, respiratory depression

Overdose –> respiratory depression, AMS, miosis, coma

53
Q

Which opioid, when taken with MAOIs, can cause serotonin syndrome?

A

Meperidine.

**Also the only opioid to cause mydriasis

54
Q

Treatment of opioid overdose

A

ABCs
Naloxone
May need ventilatory support

55
Q

Syndrome of opioid withdrawal

A

Dysphoria, insomnia, lacrimation, rhinorrhea, yawning, weakness, sweating, piloerection, nausea/vomiting, fever, mydriasis, etc.

56
Q

Treatment of opioid withdrawal

A

Moderate: Treat with clonidine for autonomic signs, NSAIDs for pain, dicyclomine for abdominal carmps
Severe: Detox with buprenorphine or methadone
Monitor with COWS (based on pulse, pupil size, tremor)

57
Q

Presentation of marijuana intoxication

A

Euphoria, anxiety, impaired coordination, tachycardia, conjunctival injection, dry mouth, and increased appetite

Can produce psychotic disorders rarely

58
Q

Withdrawal syndrome of marijuana

A

Irritability, anxiety, restlessness, aggression, strange dreams, depression, HA, sweating, chills, insomnia, anorexia

Psychiatry clerkship (11 decks)

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