Substance Related Disorders Flashcards
1
Q
What is the DSM-IV criteria for substance abuse?
A
Abuse is a pattern of substance use leading to impairment or distress for at least 1 year w/ one or more of the following manifestations:
- Failure to fulfill obligations at work, school or home
- Use in dangerous situations (driving a car)
- Recurrent substance-related legal problems
- Continued use despite social or interpersonal problems due to the substance use
2
Q
What is the DSM-IV criteria for substance dependence?
A
Dependence is a substance us leading to impairment or distress manifested by at least 3 of the following w/i a 12 mo period:
- Tolerance
- Withdrawal
- Using substance more than originally intended
- Persistent desire or unsuccessful efforts to cut down on use
- Significant time spent on getting, using or recovering from substance
- Decreased social, occupational or recreational activities because of substance use
- Continued use despite subsequent physical or psychological problem (ex: drinking despite worsening liver problems)
3
Q
A diagnosis of substance ________ supercedes a diagnosis of ________.
A
dependence, abuse
4
Q
Substance dependence
- Lifetime prevalence
- Men vs. Women
- Most commonly used substances
- What symptoms are most common
A
- Lifetime prevalence: 17%
- Men >> Women
- Caffeine, alcohol, nicotine
- Depressive symptoms
5
Q
What is the definition of withdrawal?
A
The development of a substance-specific symptom due to the cessation of substance use that has been heavy and prolonged
6
Q
What is the definition of tolerance?
A
The need for increased amounts of the substance to achieve the desired effect or diminished effect if using the same amt of the substance.
7
Q
______ is the most common co-ingestant in drug overdoses
A
Alcohol
8
Q
____% of Americans are alcoholics
A
7-10%
9
Q
Alcohol…
- ______ GABA receptors
- ______ serotonin receptors
- ______ glutamate receptors
A
- activates GABA receptors
- activates serotonin receptors
- inhibits glutamate receptors
10
Q
How is alcohol metabolized?
A
- Alcohol –> acetaldehyde
- via alcohol dehydrogenase
- Acetaldehyde –> acetic acid
- via aldehyde dehydrogenase
- Upregulation of enzymes in heavy drinkers
- Asian people have less aldehyde DH
11
Q
How do you screen for alcohol abuse?
A
CAGE questionnaire - 2 or more “yes” are positive; 1 “yes” should arouse suspicion of abuse
- Have you ever wanted to cut down on your drinking?
- Have you ever felt annoyed by criticism of your drinking?
- Have you ever felt guilty about drinking?
- Have you ever taken a drink as an “eye opener” (to prevent shakes)?
12
Q
The absorption & elimination rates of alcohol depend on what factors?
A
- Age
- Sex
- Body weight
- Speed of consumption
- Presence of food in the stomach
- Chronic alcoholism
- Presence of advanced cirrhosis
- State of nutrition
13
Q
In most states, the legal limit for alcohol intoxication is _____ mg/dL.
More than 50% of adults with BAL > ____ mg/dL show obvious signs of intoxication.
A
80-100 mg/dL
150 mg/dL
14
Q
What is the novice drinker’s BAL for each of these clinical presentations?
- Decreased fine motor control
- Impaired judgment & coordination
- Ataxic gait & poor balance
- Lethargy; difficulty sitting upright
- Coma in the novice drinker
- Respiratory depression
A
- Decreased fine motor control
- 20-50 mg/dL
- Impaired judgment & coordination
- 50-100 mg/dL
- Ataxic gait & poor balance
- 100-150 mg/dL
- Lethargy; difficulty sitting upright
- 150-250 mg/dL
- Coma in the novice drinker
- 300 mg/dL
- Respiratory depression
- 400 mg/dL
15
Q
What is the differential diagnosis for alcohol intoxication?
A
- Hypoglycemia
- Hypoxia
- Mixed EtOH-drug overdose
- Ethylene glycol or methanol poisoning
- Hepatic encephalopathy
- Psychosis
- Psychomotor seizures
16
Q
What is the diagnostic evaluation for alcohol intoxication?
A
- Serum EtOH level
- Expired air breathalyzer
- CT scan of the head
- Rule out subdural hematoma or other brain injury
17
Q
How is acute alcohol intoxication treated?
A
- Ensure adequate airway, breathing, circulation; monitor electrolytes & acid-base status
- Obtain finger-stick glucose level to exclude hypoglycemia
- Thiamine (prevent/treat Wernicke’s encephalopathy), naloxone (reverse opioid effects if ingested), folate administered
- GI evacuation (gastric lavage, charcoal) no role in treatment of EtOH overdose (mixed drug-EtOH)
18
Q
How is long-term alcohol dependence treated?
A
- Alcoholics Anonymous - self-help group
- Disulfiram (Antabuse) - aversive therapy; inhibits aldehyde dehydrogenase, causing violent retching when person drinks
- Psychotherapy & SSRIs
- Naltrexone - opioid antagonist; reduces cravings for EtOH
19
Q
The earliest symptoms of EtOH withdrawal being btwn ___ & ___ hrs after the pts last drink and depend on the _______ & _______ of EtOH consumption.
A
6-24 hrs
duration, quantity
20
Q
Clinical presentation: mild vs. severe alcohol withdrawal
A
- Mild
- Irritability, insomnia
- Severe
- Fever, disorientation, seizures, hallucinations, delirium
21
Q
What are the signs/symptoms of alcohol withdrawal syndrome?
A
- Insomnia
- Anxiety
- Tremor
- Irritability
- Anorexia
- Tachycardia
- Hyperreflexia
- Hypertension
- Fever
- Seizures
- Hallucinations
- Delirium
22
Q
What is delirium tremens?
How many pts experience it?
What are the symptoms?
A
- Most serious form of EtOH withdrawal
- Begins w/i 72 hrs of cessation of drinking
- Only 5% of pts hospitalized for EtOH withdrawal
- 15-20% mortality rate if untreated
-
Symptoms
- Delirium
- Visual/tactile hallucinations
- Gross tremor
- Autonomic instability
- Fluctuating levels of psychomotor activity
23
Q
How is alcohol withdrawal diagnostically evaluated?
A
- Accurate & frequent assessment of vitals
- Autonomic instability may occur
- Careful attention to level of consciousness
- Possibility of trauma should be investigated
- Signs of hepatic failure may be present
- Ascites, jaundice, caput medusae, coagulopathy
24
Q
What is the differential diagnosis of alcohol withdrawal?
A
- Alcohol-induced hypoglycemia
- Acute schizophrenia
- Drug-induced psychosis
- Encephalitis
- Thyrotoxicosis
- Anticholinergic poisoning
- Withdrawal from other sedative-hypnotic type drugs
25
How is alcohol withdrawal treated?
* Tapering doses of benzodiazepines
* chlordiazepoxide, lorazepam
* Thiamine, folic acid, multivitamin to treat nutritional deficiencies
* Mg sulfate for postwithdrawal seizures
26
Wernicke-Korsakoff syndrome is caused by....
* Thiamine (vitamin B1) deficiency
* Poor diet of alcoholics
27
What is Wernicke's encephalopathy?
* Acute & reversed by thiamine therapy
* Triad
* Ataxia
* Confusion
* Ocular abnormalities (nystagmus, gaze palsies)
* May progress to Korsakoff's syndrome if left untreated
28
What is Korsakoff's syndrome?
* Progression from Wernicke's encephalopathy
* Chronic, often irreversible
* Triad
* Impaired recent memory
* Anterograde amnesia
* +/- confabulation
29
What is confabulation?
making up answers when memory has failed
30
What is the mechanism of cocaine?
* Blocks dopamine reuptake from the synaptic cleft
* Stimulant effect
* Dopamine plays a role in behavioral reinforcement ("reward" system of the brain)
31
What is the clinical presentation of cocaine intoxication?
**"flight or fight" response**
* Euphoria
* Increased/decreased BP
* Tachycardia/bradycardia
* Nausea
* Dilated pupils
* Weight loss
* Psychomotor agitation & depression
* Chills
* Sweating
* Respiratory depression
* Seizures
* Arrhythmias
* Hallucinations (tactile)
32
Cocaine's vasoconstrictive effect may result in _____ or \_\_\_\_\_.
Myocardial infarction
Cerebrovascular accident
33
What is the differential diagnosis of cocaine intoxication?
* Amphetamine or PCP intoxication
* Sedative withdrawal
34
What is the diagnostic evaluation for cocaine intoxication?
* Urine drug screen
* Positive for 3 days, longer in heavy users
35
How is cocaine intoxication treated?
* Mild-to-moderate agitation: benzodiazepines
* For severe agitation or psychosis: haloperidol
* Symptomatic support
* Control HTN, arrhythmias, etc.
36
How is cocaine dependence treated?
* Psychotherapy, group therapy
* TCAs
* Dopamine agonists (amantadine, bromocriptine)
37
How does cocaine withdrawal present clinically?
How is it treated?
* Abrupt abstinence is not life threatening but produces a dysphoric "crash"
* Malaise, fatigue, depression, hunger, constricted pupils, vivid dreams, psychomotor agitation or retardation
* Treatment usually supportive; let pt sleep off crash
38
What are the 3 classic amphetamines?
* Dextroamphetamine (Dexedrine)
* Methylphenidate (Ritalin)
* Methamphetamine (Desoxyn, ice, speed, "crystal meth", "crack")
39
What are the 2 substituted "designer" amphetamines?
* MDMA (ecstasy)
* MDEA (eve)
40
What is the mechanism of classic amphetamines?
* Release dopamine from nerve endings
* Stimulant effect
* Used medically in treatment of narcolepsy, ADHD & depressive disorders
41
What is the mechanism of designer amphetamines?
* Release dopamine & serotonin from nerve endings
* Have both stimulant & hallucinogenic properties
42
Amphetamine intoxication causes symptoms similar to those of \_\_\_\_\_\_.
cocaine
43
What is the differential diagnosis of amphetamine intoxication?
* Cocaine or PCP intoxication
* Chronic use in high doses may cause a psychotic state similar to schizophrenia
44
What is the diagnostic evaluation for amphetamine intoxication?
* UDA (positive for 1-2 days)
* Negative routine drug screen doesn't rule it out
* Most assays not of adequate sensitivity
* **Negative drug screen can NEVER completely rule out substance abuse or dependence**
45
Treatmentof amphetamine intoxication/withdrawal of amphetamines is similar to \_\_\_\_.
cocaine
46
What is the mechanism of PCP?
* "angel dust"
* Hallucinogen that antagonizes N-methyl-D-aspartate (NMDA) glutamate receptors & activate dopaminergic neurons
* Ketamine similar to PCP (anesthetic agents)
47
\_\_\_\_\_\_\_\_\_\_ is pathognomonic for PCP intoxication.
More than with other drugs, intoxication w/ PCP results in \_\_\_\_\_\_\_.
Rotary nystagmus
violence
48
How does PCP intoxication present?
Overdose?
* Intoxication
* Recklessness
* Impulsiveness
* Impaired judgment
* Assaultiveness
* Rotatory nystagmus
* Ataxia
* HTN
* Tachycardia
* Muscle rigidity
* High tolerance or pain
* Overdose
* Seizures, coma
49
How is PCP intoxication treated?
* Monitor BP, temp, electrolytes
* Acidify urine w/ ammonium chloride & ascorbic acid
* **Benzodiazepines** or **dopamine antagonists** to control agitation & anxiety
* **Diazepam** for muscle spasms & seizures
* **Haloperidol** to control severe agitation or psychotic symptoms
50
What is the differential diagnosis for PCP intoxication?
* Acute psychotic states
* Schizophrenia
51
What is the diagnostic evaluation for PCP intoxication?
* Urine drug screen (positive for \>1 wk)
* Creatine phosphokinase (CPK) & aspartate aminotransferase (AST) are often elevated
52
How does PCP withdrawal clinically present?
* No withdrawal syndrome
* "Flashbacks" may occur
53
What types of sedatives/hypnotics are typically abused?
* **Benzodiazepines**
* Used to treat anxiety disorders
* Obtained via prescription
* Potentiates GABA by increasing frequency of chloride channel opening
* **Barbiturates**
* Used to treat epilepsy; anesthetic
* Potentiates GABA by increasing duration of chloride channel opening
* High doses: act as direct GABA agonists; lower margin of safety compared to BDZs
* Benzos & Barbs are synergistic in their complementary effect on GABA channel opening
* _Respiratory depression_ can be a complication
54
What is Gamma-hydroxybutyrate (GHB)?
"Grievous Bodily Harm"
* Dose-specific CNS depressant that produces memory loss, respiratory distress, coma
* Commonly used as a date-rape drug
55
What is the clinical presentation of sedative-hypnotic intoxication?
Symptoms are augmented when combined with \_\_\_\_.
* Drowsiness
* Slurred speech
* Incoordination
* Ataxia
* Mood lability
* Impaired judgment
* Nystagmus
* Respiratory depression
* Coma/death in overdose (esp barbs)
* Symptoms augmented w/ EtOH
* Long-term sedative use causes dependence
56
What is the differential diagnosis for sedative-hypnotic intoxication?
* Alcohol intoxication
* Generalized cerebral dysfunction (ex: delirium)
57
What is the diagnostic evaluation for sedative-hypnotic intoxication?
* Urine or serum drug screen (positive for 1 wk)
* Electrolytes
* ECG
58
How is sedative-hypnotic intoxication treated?
* Maintain airway, breathing, circulation
* Activated charcoal to prevent further GI absorption
* For *barbiturates* only
* Alkalinize urine w/ sodium bicarbonate to promote renal excretion
* For *benzos* only
* Flumazenil in overdose
* Supportive care
* Improve respiratory status, control hypotension
59
What is Flumazenil?
* Very short-acting BDZ antagonist
* Use w/ caution when treating overdose, as it may precipitate seizures
60
What is the clinical presentation of sedative-hypnotic withdrawal?
* Autonomic hyperactivity (tachycardia, sweating)
* Insomnia
* Anxiety
* Tremor
* Nausea/vomiting
* Delirium
* Hallucinations
* Seizures may occur (can be life-threatening)
61
In general, withdrawal from drugs that are ________ is life threatening, while withdrawal from ______ & _______ is not.
sedating
stimulants, hallucinogens
62
How is sedative-hypnotic withdrawal treated?
* Admin of long-acting benzodiazepine (chlorodiazepoxide, diazepam) w/ tapering of the dose
* Tegretol or valproic acid may be used for seizure control
63
\_\_\_\_\_\_\_\_\_\_\_\_ is a common ingredient in cough syrup.
dextromethorphan
64
**Opiates**
* Examples
* Mechanism of action
* Endogenous vs. exogenous
* Heroin, codeine, dextromethorphan, morphine, methadone, meperidine (Demerol)
* Stimulate **opiate receptors (mu, kappa, delta)** which are stimulated by endogenous opiates
* Analgesia, sedation, dependence
* Mediates addictive & rewarding properties through effects on the **dopaminergic system**
* Endogenous opiates: endorphins, enkephalins
65
What is the clinical presentation of opiate intoxication?
* Drowsiness
* Nausea/vomiting
* Constipation
* Slurred speech
* Constricted pupils
* Seizures
* Respiratory depression
* Coma/death in overdose
66
What is serotonin syndrome?
How is it caused?
* Caused by combination of meperidine & monoamine oxidase inhibitors
* Hyperthermia, confusion, hyper/hypo-tension & muscular rigidity
67
What is the differential diagnosis for opiate intoxication?
* Sedative-hypnotic intoxication
* Severe EtOH intoxication
68
What is the diagnostic evaluation for opiate intoxication?
* Rapid recovery of consciousness following the admin of IV naloxone (opiate antagonist)
* Urine & blood tests remain positive for 12-36 hrs
69
How is opiate **intoxication** treated?
Ensure adequate airway, breathing, circulation
70
How is opiate **overdose** treated?
Admin of *naloxone* or *naltrexone* (opiate antagonists)
* Will improve respiratory depression
* May cause severe withdrawal in an opiate-dependent patient; ventilatory support may be required
71
How is opiate **dependence** treated?
* Oral methadone once daily, tapered over months to years
* Psychotherapy, support groups (Narcotics Anonymous, etc)
72
\_\_\_\_\_\_\_\_\_ is the exception to opioids producing miosis.
Meperidine
"Demerol dilates pupils)
73
What is the classic triad of opioid overdose?
"**R**ebels **A**dmire **M**orphine"
* Respiratory depression
* Altered mental status
* Miosis
74
What is the clinical presentation for opiate withdrawal?
* Not life threatening
* Dysphoria
* Insominia
* Lacrimation
* Rhinorrhea
* Yawning
* Weakness
* Sweating
* Piloerection
* Nausea/vomiting
* Fever
* Dilated pupils
* Muscle ache
75
How is opiate withdrawal treated?
* Moderate symptoms
* Clonidine and/or buprenorphine
* Severe symptoms
* Detox w/ methadone tapered over 7 days
76
What are some examples of hallucinogens?
What effects do they have?
* Psilocybin (mushrooms), mescaline, lysergic acid diethylamide (LSD)
* Pharmacological effects vary
* LSD known to act on serotonergic system
* Tolerance to hallucinogens develops quickly but reverses rapidly after cessation
* Don't cause physical dependence or withdrawal
77
What is the clinical presentation and treatment of hallucinogen intoxication?
* Perceptual changes, papillary dilation, tachycardia, tremors, incoordination, sweating, palpitations
* Guidance & reassurance ("talking down" the patient) are usually enough
* Severe cases: antipsychotics or benzos
78
Describe hallucinogen withdrawal
* No withdrawal syndrome is produced
* Patients may experience "flashbacks" later in life (recurrence of symptoms due to reaborption from lipid stores)
79
What do methyl pemolines produce?
* 92C-B, U4EUH, Nexus
* Classic psychedelic distortion of senses
* Feeling of harmony, anxiety, paranoia, panic
80
What can Ketamine produce symptomatically?
"special K"
* Tachycardia, tachypnea w/ hallucinations at higher doses
* Amnesia & numbed confusion
81
What is the main component of marijuana?
What is the mechanism of action?
How is it used?
* THC (tetrahydrocannabinol)
* Cannabinoid receptors in the brain inhibit adenylate cyclase
* Effects increased when used w/ EtOH
* Marijuana shown to successfully treat *nausea* in cancer patients & increase *appetite* in AIDS patients
* No dependence or withdrawal syndrome has been shown
82
What are the clinical symptoms of marijuana intoxication?
* Euphoria
* Impaired coordination
* Mild tachycardia
* Conjunctival injection
* Dry mouth
* Increased appetite
83
What is the treatment & diagnostic evaluation for marijuana intoxication?
* Supportive & symptomatic
* Urine drug screen is positive for up to 4 wks in heavy users (released from adipose stores)
84
What is the clinical presentation & treatment of marijuana withdrawal?
* No withdrawal syndrome
* Mild irritability, insomnia, nausea, decreased appetite in heavy users
* Treatment: supportive & symptomatic
85
What are some examples of inhalants?
* Solvents, glue, paint thinners, fuels, isobutyl nitreates ("rush", "locker room", "bolt")
* Inhalants generally act as CNS depressants
* User is typically an adolescent male
86
What is the clinical presentation of inhalent intoxication?
* Impaired judgment, belligerence, impulsivity, perceptual disturbances, lethargy, dizziness, nystagmus, tremor, muscle weakness, hyporeflexia, ataxia, slurred speech, euphoria, stupor, coma
* Overdose may be fatal
* Respiratory depression
* Arrhythmias
* Long-term use may cause permanent damage
* CNS, PNS, liver, kidney, muscle
87
What is the diagnostic evaluation & treatment for inhalent intoxication?
* Serum drug screen (positive for 4-10 hrs)
* Treatment
* Monitor airway, breathing, circulation
* Symptomatic treatment as needed
* Psychotherapy & counseling for dependent patients
88
What is the clinical presentation of inhalent withdrawal?
* Withdrawal syndrome does not usually occur
* Symptoms may include
* Irritability
* Nausea/vomiting
* Tachycardia
* Occasional hallucinations
89
What is the mechanism of caffeine?
* Most commonly used psychoactive substance in the US (coffee, tea)
* Adenosine antagonist
* Increases cAMP
* Stimulates dopaminergic system
90
How much caffeine is in one cup of coffee? tea?
* One cup of coffee: 100-150 mg
* One cup of tea: 40-60 mg
91
What is the clinical presentation of caffeine intoxication?
How is it treated?
* **\>250 mg caffeine**
* Anxiety, insomnia, twitching, rambling speech, flushed face, diuresis, GI disturbance, restlessness
* **\>1 g caffeine**
* Tinnitus, severe agitation, cardiac arrhythmias
* **\>10 g caffeine**
* Death secondary to seizures & respiratory failure
* Treatment: supportive & symptomatic
92
What is the clinical presentation & treatment of caffeine withdrawal?
* Withdrawal symptoms resolve w/i 1 wk
* Headache, nausea/vomiting, drowsiness, anxiety, depression
* Treatment
* Taper consumption of caffeine-containing products
* Use analgesics to treat headaches
* Short course of benzos for anxiety (rare)
93
What is the mechanism of action of nicotine?
* Derived from the tobacco plant
* Stimulates nicotinic receptors in autonomic ganglia of the _sympathetic_ & _parasympathetic_ nervous systems
* Cigarette smoking poses many health risks
* Nicotine rapidly **addictive** through effects on dopaminergic systems
94
Cigarette smoking during pregnancy is associated with.....
low birth weight
persistent pulmonary HTN of newborn
95
What is the clinical presentation & treatment of nicotine intoxication?
* CNS stimulant
* Restlessness, insomnia, anxiety, increased GI motility
* Improved attention, improved mood, decreased tension
* Treatment: cessation
96
What is the clinical presentation & treatment of nicotine withdrawal?
* Intense craving, dysphoria, anxiety, increased appetite, irritability, insomnia
* Treatment: smoking cessation with...
* Behavioral counseling
* Nicotine replacement therapy (gum, transdermal patch)
* Zyban: antidepressant that helps reduce cravings
* Clonidine
* Relapse after abstinence is common
