Substance Use Flashcards
1
Q
What is addiction? (DSM-4)
A
- Substance use
- Use/procurement despite problems
- Return to use after period of abstinence
- Inability to control use
- Pre-ocupation
- Cognitive changes (over-valuation, de-valuation, minimization/denial)
- Enhanced cue responsiveness via conditioning/generalization
2
Q
What are different aspects of recovery?
A
- Clinical (absence of sx)
- Social
- Economic
- Personal
3
Q
What is dependence? (DSM-4)
A
Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifest by 3+ of the followed w/in the same 12 months:
- Tolerance
- Withdrawal
- Using more or for longer than intended
- Inability to cut-down/control
- Takes up your time (to get it or to recover)
- Activities reduced
- Continued use despite problems
4
Q
What personality d/o has the highest incidence of substance use d/o?
- What 2 mood d/o’s come in 2nd and 3rd?
A
- Anti-social personality d/o
- BD
- Schizophrenia
5
Q
How many ounces in 1 drink of liquor?
Beer?
Wine?
A
Liquor: 1 oz
Beer: 12 oz
Wine: 4oz
6
Q
What % of 12th-graders have been drunk once in the last month?
A
26.8%
(14.7% 10th graders)
(5% 8th graders)
7
Q
When is the first episode of etoh intoxication likely to occur?
- When does are of onset of etoh DEPENDENCE peak?
A
Mid-teens
- Peaks 18-25 y/o
8
Q
What are the signs of etoh intoxication?
A
- Slurred speech
- Incoordination
- Unsteady gait
- Nystagmus
- Impaired attn or memory
- Stupor or coma
9
Q
What are the possible somatic tx’s for acute intoxication w/etoh?
A
- Reassurance
- Maintenance in a safe/monitored environment
- Decrease external stimulation
- Provide orientation and reality testing
10
Q
When does mild-mod etoh withdrawal start?
- What are some s/s?
A
W/in first several HRS s/p cessation/reduction of heavy drinking
- N/V
- Anxiety
- Tachycardia
- Irritability
- HTN
- Autonomic hyperactivity
- Tremors
- Insomnia
11
Q
When do etoh withdrawal sx peak?
A
2nd day of abstinence
12
Q
When do etoh withdrawal sx usually resolve?
A
4-5 days after withdrawal sx peak (~6-7 days total)
13
Q
When does severe etoh withdrawal occur?
- What are some s/s?
A
W/in 1st several DAYS s/p cessation/reduction
- Clouding of consciousness
- Trouble sustaining attn
- Disorientation
- Grand mal seizures
- Fever
- Respiratory alkalosis
- Hallucinations
- Delirium
14
Q
What are the two main goals of mod/severe etoh withdrawal tx?
A
- Reduce CNS irritability
2. Restore physiologic homeostasis
15
Q
Which pts undergoing etoh withdrawal will likely require hospitalization?
A
- H/o withdrawal seizure
- H/o DTs
- Documented h/o heavy etoh use and high tolerance
- Concurrently abusing other substances
- Severe co-morbid medical/psychiatric d/o
16
Q
What is CIWA-Ar?
- How many items are in it?
- Why do we use it?
A
Etoh withdrawal protocol (rates severity and freq of sx)
- 10-item (scored 0-7)
- Guides drug use
17
Q
What CIWA score indicates mild withdrawal?
Mod?
Severe?
A
- Mild: = <10
- Mod: 10-19
- Severe: >20
(some ppl use different cutoffs)
18
Q
What is the tx for mild etoh withdrawal?
A
- Generalized support
- Reassurance
- Frequent monitoring
19
Q
What is the tx for mod/severe etoh withdrawal? (3)
A
- BZDs
- Thiamine
- Fluids
20
Q
What is “kindling,” w/r/t etoh withdrawal?
A
Repeated episodes of withdrawal may lead to a worsening of future withdrawal episodes
(these pts require more aggressive tx)
21
Q
When considering pharm tx for mod/severe etoh withdrawal, what factors should you consider?
A
- Relieves sx
- Prevents seizures/delirium
- Benign side effects
- Relatively safe in OD
22
Q
What route of BZDs can you use in etoh withdrawal?
A
- PO a/o IV
- Do not use IM
(Definite info regarding which BZD is superior does not exist)
23
Q
Compare and contrast the equivalent doses of alprazolam, chlordiazepoxide, clonazepam, chlorazepate, diazepam, lorazepam, and oxazepam.
A
- Clonazepam: 0.5mg
- Alprazolam: 1mg
- Lorazepam: 2mg
- Diazepam: 10mg
- Chlorazapate: 15mg
- Oxazepam: 15mg
- Chlordiazepoxide: 20mg
24
Q
Compare and contrast the onset speeds of alprazolam, chlordiazepoxide, clonazepam, chlorazepate, diazepam, lorazepam, and oxazepam.
A
- Diazepam: very fast
- Chlorazapate: fast
- Clonazepam: intermediate
- Alprazolam: intermediate
- Lorazepam: intermediate
- Chlordiazepoxide: intermediate
- Oxazepam: slow
25
Compare and contrast the T1/2's of alprazolam, chlordiazepoxide, clonazepam, chlorazepate, diazepam, lorazepam, and oxazepam.
- Alprazolam: short
- Lorazepam: short
- Oxazepam: short
- Clonazepam: long (18-50 hrs)
- Chlordiazepoxide: long (30-200 hrs)
- Chlorazapate: long (30-200 hrs)
- Diazepam: long (30-200 hrs)
26
What is the tx for CIWA-Ar < 9?
No dosing required; monitor w/q4H CIWA
27
What is the BZD tx for CIWA-Ar 10-20?
- Lorazepam 2mg
- Diazepam 10mg
- Chlordiazepoxide 50mg
28
What are the tx considerations for CIWA-Ar >20?
Consider tx in a more highly monitored setting (eg ICU)
| - Consider more aggressive BZD dosing
29
In ETOH withdrawal, which BZDs are indicated for pts w/severe hepatic dz, elderly, or dementia?
(short or long-acting?)
Short-acting
- Lorazepam
- Oxazepam
30
*What are the features of DTs?
- Autonomic hyperactivity (tachycardia, diaphoresis, fever, hypotension)
- Insomnia
- Perceptual disturbances
- Hallucinations (visual, tactile)
- Fluctuating level of psychomotor activity
31
Why are DT's considered a medical emergency?
- May be assaultive or suicidal
- May act on hallucinations
- Often preceded by seizures
- May appear de novo
32
*What is the % mortality for ETOH withdrawal delirium?
1%
33
What is the tx for DTs during etoh withdrawal?
- Best tx is prevention
- BZDs to calm and raise seizure threshold
- Consider seclusion
- Fluids (PO if tolerated, or IV)
- Skilled verbal support
34
What drugs can be used to reduce signs of autonomic hyperactivity during DTs?
- BBs (eg propranolol) for tremor, tachycardia, HTN, and diaphoresis
35
Can alpha-agonists help in tx of DTs?
- Yes, can reduce tremor, HR, and BP
| eg clonidine
36
What anticonvulsants may be useful during DTs?
- Carbamazepine (Tegretol)
- Divalproex sodium (Depakote)
- Benzos
37
What is the brand name for acamprosate?
Campral
38
What is the brand-name for extended release IM naltrexone?
Vivatrol
39
What is the brand-name for PO form of naltrexone?
Revia
40
- What is the MoA of naltrexone?
| - What is its role in ETOH use d/o tx?
- Opioid antagonist
- Prevents opioid-mediated euphoria and rewarding effects of etoh
- Blunts subsequent craving for etoh
- Better than PBO; reduces heavy drinking days; decreases rates of relapse
41
In etoh tx, naltrexone appears to work better when combined w/....
Psychosocial tx's
- Relapse prevention
- CBT
- Coping skills
42
What are the side effects of naltrexone (vivatrol, revia)
* Hepatotoxicity
* Ppt's opioid withdrawal
- HA
- Fatigue
- Dysphoria
- N/V
- Abd pain
43
When is hepatotoxicity more likely w/ naltrexone?
In morbidly obese or at high doses
44
What is the MoA of acamprosate (Campral) in etoh withdrawal/tx?
- A GABA analogue
- Presumed to work at glutamate receptor sites -
Normalizes aberrant glutamate system that occurs in protracted withdrawal and cravings (decreases cravings)
45
When should acamprosate be started? (before or after stopping drinking)
What are the benefits pts see w/ use of acamprosate?
Start it once they've stopped drinking
- Increased time prior to relapse
- More abstinent days during year of tx
* Can be used in liver disease (excreted renally)
46
What are adverse effects of acamprosate?
When is it contraindicated? (1)
- Well-tolerated
- Diarrhea
Contraindicated in renal disease.
47
Brand name for disulfiram?
Antabuse
48
What does disulfiram do?
| - What is MoA of disulfiram?
Aversive therapy
| - Inhibits aldehyde DH, increasing blood levels of acetaldehyde
49
What are the effects of disulfiram?
- Heat in face/neck
- HA
- Flushing
- N/V
- Hypotension
- Anxiety
- Tachycardia
- SOB
50
Who are the best candidates for disulfiram tx?
- Intelligent
- Motivated
- Not impulsive
- Drinking triggered by unanticipated internal ro external cues
(NEVER use w/o pts knowledge/consent)
51
What are the contraindications for disulfiram?
| * What rxn can it cause?
- Highly impulsive
- Poor judgment
- Severe co-existing psych illness
* May cause "alcohol-antabuse" reaction 1-2 wks s/op last dose
52
__% of US population has tried cocaine w/ __% report using in last year.
10% tried
| 20% did in last yr
53
Lifetime rate of cocaine abuse or dependence?
2%
54
What % of cocaine users smoke crack?
33%
55
What age range has highest cocaine use?
18-25, 26-34
56
Sex differences b/w cocaine users?
M x2 > F
57
Routes of cocaine use?
#Which is most potent/addictive?
- Snorting (tooting)
- SQ ("skin popping"
- IV
- #Smoking (freebasing/basing)
- PO (rare)
58
T1/2 cocaine?
1 hr
59
Major metabolite of cocaine and when can it be detected?
Benzoyelcgonine
| - 2-3 days s/p single use
60
Cocaine MoA?
Blocks pre-synaptic reuptake of NE and DA (excess at post-synaptic receptors)
61
S/s of cocaine intoxication?
- Tachycardia
- HTN
- Tachypnea
- Hyperthermia
- Agitation
- Pupillary dilatation
- Peripheral vasoconstriction
- Seizures
- Elation/euphoria
- ^ self-esteem
- Perceived improvement on mental/physical tasks
62
What is the general tx for cocaine intox? (2)
- Supportive
| - Treat sx of autonomic hyperactivity
63
What s/s can be seen at very high doses of cocaine intoxication?
- Agitation
- Irritability
- Impaired judgment
- Impulsive and potentially dangerous sexual behaviors
- Aggression
64
Most common causes of cocaine-related deaths?
- Cardiac (arrhythmias; MI)
| - CNS (hemorrhage, infarct, seizures)
65
When does cocaine withdrawal start/end?
Few hrs - several days after cessation of use
66
S/s of cocaine withdrawal?
- Depression
- Fatigue
- Dysphoria
- Sleep disturbance
- Anxiety
- Anhedonia
- Appetite changes
67
How long does the cocaine crash last usually? How long can it last?
- 9-12 hrs, up to 9 days
68
Cocaine withdrawal can mimic what mood d/o's?
Unipolar or bipolar depression
69
What CNS NT systems do opioids act on?
- DA
- GABA
- Glutamate
70
What are some clinical indications for opioid use?
- Pain
- Cough
- Diarrhea
- Opioid detox (specialized use)
71
How does heroin differ from morphine in terms of potency, lipid solubility?
Heroin:
- More potent than morphine
- Liquid soluble
72
How many current heroin users are there?
~1mil
73
Sex differences b/w heroin users?
M x3 : F
74
When does opioid dependence usually occur?
| What about ppl w/current dependence?
Mid 20s - 30s
| most ppl w/current dependence: 30s-40s
75
What % of 12-graders have used oxycontin?
5. 1%
(4. 6% 10th graders)
(2. 1% 8th graders)
76
What % of 12-graders have used vicodin?
8. 0%
(7. 7% 10th graders)
(2. 7% 8th graders)
77
What are the 3 types of opioid receptors?
- Mu
- Kappa
- Delta
78
What do mu-opioid receptors mediate?
- Analgesia
- Respiratory depression
- Constipation
- Dependence
79
What do kappa-opioid receptors mediate?
- Analgesia
- Diuresis
- Sedation
80
What do delta-opioid receptors mediate?
Possibly analgesia
81
What are the routes of opioids?
All (PO, smoking, nasal, SQ, IM, IV)
82
What are the s/s of opioid intoxication?
- Altered mood
- Psychomotor retardation
- Drowsiness "nodding"
- Slurred speech
- Impaired memory/attn
- Pupillary constriction
- Feelings of warmth
- Itchy face and extremities
- Facial flushing
83
What are the s/s of opoid OD?
- Marked unresponsiveness
- Coma
- Slow respirations
- Hypothermia
- Hypotension
- Bradycardia
84
*What is the clinical triad of opioid OD?
- Unresponsiveness/coma
- Pinpoint pupils
- Respiratory depression
85
What is the tx for opioid OD?
- Airway
- Naloxone (0.4mg IV); may repeat 4-5x; sometimes given IM
- Careful observation
86
Brand name of naloxone?
*T1/2?
Narcan
* 45 min
87
What are opioid withdrawal s/s?
- Muscle cramps
- Diarrhea
- Abdominal cramps
- Dysphoric mood
- N/V
- Rhinorrhea
- Piloerection
- Yawning
- *Flu-like sx
88
When does heroin withdrawal start after last dose?
When does heroin withdrawal peak?
When does heroine withdrawal subside?
6-8 hrs
2nd or 3rd day
7-10 days after peaking
89
What are the goals of heroin tx?
- Abstinence from all illicit opioid use
| - Substantial decrease in use (harm reduction)
90
What are the different tx settings for heroin?
- Inpt hospital
- Outpt clinics/offices
- Opioid tx programs
- Self-help programs
- Therapeutic communities
91
What is the most common form of pham tx for opioid dependence?
Methadone Maintenance (opioid maintenance therapy - OMT)
92
Methadone MoA?
Mu-opioid agonist
- Orally active
- Can be dosed once daily
- Suppresses withdrawal
- Blocks effect of other opioids
93
What CYP enzyme metabolizes methadone?
Methadone T1/2?
3A4
T1/2: ~24 hrs
94
When does methadone withdrawal typically begin?
When does it typically subside?
1-3 days s/p last dose
Subsides in 10-14 days
95
Most common side effects of methadone?
- Constipation
- Sweating
- Sedation
- Sexual dysfcn
- QTc prolongation
- Low T
96
Opioid maintenance therapy is effective in: (read)
- Decreasing use
- Decreasing psychosocial and medical morbidity
- Improving overall health status
- Decreasing mortality
- Decreasing criminal activity
- Improving social fcning
97
Brand name of buprenorphine alone?
Subutex
98
What is the MoA of buprenorphine?
Mixed opioid partial agonist/antagonist
- Produces partial agonist effect at mu receptor
- Antagonizes kappa receptor
99
What is Suboxone (how is it different from Subutex?
Buprenorphine + naloxone
| Subutex is buprenorphine alone
100
Buprenorphine:
- Onset of effects?
- Peak effects?
- Duration?
- T1/2?
- Onset: 30-60 min
- Peak: 1-4 hrs
- Depends on dose, 8-72 hrs
- 24-37 hrs
101
Which CYP enzyme metabolizes buprenorphine?
3A4
102
How severe physical opioid dependence should pts have to receive buprenorphine vs. methadone?
- Buprenorphine: mild-mod
| - Methadone: severe
103
What's are some adjunctive pharm tx's used in opioid withdrawal? (read)
- Clonidine (alpha2 agonist) for N/V/D, cramps, sweating
- Anti-spasmotics (dicyclmine)
- Anti-emetics (trimethobenzamide)
- Anti-diarrheals (loperamide)
- NSAIDs
- BZDs
- Diphenhydramine
- Hydroxyzine
- Sedating anti-depressants (doxepin, amitriptyline)
104
What % of 12th graders have used marijuana?
- 49%
(40% 10th graders)
(20.4% 8th graders)
105
What questions should you ask during drug screening?
- Types used
- Age at 1st use
- Period of heaviest lifetime use
- Use past 3 months
- Presence of tolerance or withdrawal
106
Recall the CAGE screening questions.
- Felt need to CUT down on drinking
- Feel ANNOYED when asked about drinking
- Feel GUILTY about drinking
- Ever needed an EYEOPENER
107
How do you interpret CAGE results?
- 2+ positive = considered probably alcoholism
- 1 positive = warrants further evaluation
- Not recommended as a screening tool but…can be useful for quickly finding out if someone who screens positive on a single-item screening question has or has had a more severe problem (by answering two or more as “yes”)
108
What does MAST stand for?
- What is it used for?
- How many questions is it?
Michigan Alcoholic Screening Test
- Used to assess alcoholic potential
- 25 items
109
What are the reasons to do brief therapies for etoh intervention?
- Enhance entrance into alcoholism tx
- Education about substance abuse and dependence
- Decrease etoh consumption for 12 mo
- Cuts health care utilization
- Reduces societal and health costs
110
What is considered healthy alcohol use for men under 65?
Women?
14 drinks per week, 4 or less any day
7 drinks per week, 3 (2?) or less any day
111
What is the overall prevalence of etoh use d/o?
8.5%
112
What is the overall prevalence of substance use d/o?
2%
113
What is the criteria for substance use d/o?
| how many criteria to consider mild? Mod? Severe?
A problematic pattern of use leading to clinically significant impairment or distress is manifested by 2 or more of the following w/in 12-month period:
- Using more than intended
- Desire or failing to cut down
- Times spent trying to obtain/use/recover
- Recurrent use despite problems
- Giving up activities that are important
- Using in hazardous conditions
- Tolerance
- Withdrawal
(mild = 2-3, mod = 4-5, severe = 6+)
114
What does SBIRT stand for?
- Screening
- Brief Intervention
- Referral Tx
115
Which adults should be screened for unhealthy etoh use?
All (those w/unhealthy use should receive brief counseling intervention)
116
If someone is already known to have substance use problems, what should you do instead of screening?
Full assessment for substance use d/o's
117
Describe the 2 questions used in "Single Item Screening"
| - When is it positive?
“Do you sometimes drink beer, wine or other alcoholic beverages?” IF YES:
- How many times in the past year have you had 5 (4 for women) or more drinks in a day?
- Test is is positive when response > 0 or when the patient states he/she is having difficulty coming up with the # (because it is therefore > 0)
118
What does AUDIT stand for?
How many questions is it?
Alcohol use d/o identification test (review it online)
- 10-item questionnaire (takes longer than single-item screening); score ranges 0-40
> 8 = unhealthy use
>/= 20 = dependence
119
Give an eg of a single-item screening question for substance use.
“How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?”
- Response > 0 is + test
120
What is DAST?
- Score ≥ __ w/ 10 yes/no items suggests drug use w/ adverse consequences
- When may it be useful?
"Drug Abuse Screening Test"
- Score ≥ 3 w/ 10 yes/no items suggests drug use w/ adverse consequences
- May have some utility for assessing severity
121
What does SoDU stand for?
Screening of Drug Use (d/o)
122
What can serum/urine drug panels typically detect?
* Opiates
* Cocaine
* Marijuana
* Benzodiazepines
* Barbiturates
* Acetaminophen
* Alcohol
* Aspirin
(Possibly false positives may require confirmation with gas chromatography-mass spectrometry)
123
If a pt screens positive for etoh use, what questions should you ask next?
Ask about consumption:
• On average, how many days per week do you drink alcohol?
• On a typical day when you drink, how many drinks do you have?
• What is the maximum number of drinks you had on any given occasion during the last month?
124
Read about some major medical consequences of drug/etoh abuse.
- Cocaine: CV, pulm
- Drug-induced myopathies
- Drug-induced neutropenia and agranulocytosis
- Leukoencephalopathy due to heroin inhalation
- Injection drug use: Hepatitis C, HIV
125
What are the goals of brief intervention in mild substance abuse d/o?
- Abstinence or reduced use
126
What are the goals of brief intervention in mod-severe substance abuse d/o?
Pt to enter and participate in SUD specialty care
| *if at-risk for withdrawal, must first undergo detox
127
What are endorphins?
Subclass of opioids consisting of endogenous peptides that cause pain relief, including:
- enkephalins
- dynorphins
- beta-endorphins
128
Fentanyl and methadone are a subclass of opioids called ____________ opioids.
Synthetic
129
Oxycodone and hydrocodone are a subclass of opioids called ____________ opioids.
Semisynthetic
130
What are some health consequences of opioid use disorder?
- Increased mortality
- Overdose
- Infections
- Endocarditis
- Narcotic bowel syndrome
- Accident-related injuries (increased rate vs general pop)
131
Urine drug tests can detect metabolites of heroin and morphine within __ days of last use.
3
132
What are some things that can cause false-positives on UDS?
- Rifampin
- Quinolones
- Poppy seeds
133
In early opioid remission: After full criteria were previously met, none of the criteria for OUD have been met (with the exception of craving) for at least __ months but < __ months.
3, 12
134
In sustained opioid remission: After full criteria were previously met, none of the criteria for OUD have been met (with the exception of craving) during a period of ≥ __ months
12
135
When should naloxone be provided?
- Any illicit opioid use (including those receiving/discontinuing tx for OUD)
- Suspected opioid use d/o
- Receiving Rx'd opioids +... (50 morphine +, BZDs/other sedating drugs, h/o substance use d/o, h/o opioid OD)
- Risk of witnessing opioid OD
136
When should opioids be Rx'd?
* Other alternative therapies have not provided sufficient pain relief and:
* Pain is adversely affecting a pt's fcn and/or QoL and
* When the potential benefits of opioid therapy outweigh potential harms
137
What are the S.M.A.R.T. goals to use w/opioid prescribing?
```
Specific
Measurable
Attainable
Relevant
Time-limited
```
138
What should you always remind pt about goals w/opioid therapy?
They do not include being completely pain-free!
139
What a good tapering strategy when discontinuing opioids?
25% dose reduction per week
140
Which benzos are best to use in liver disease?
LOT
- Lorazepam
- Oxazepam
- Temazepam
141
Provide the brand names for the following:
- Clonazepam
- Alprazolam
- Lorazepam
- Diazepam
- Chlorazapate
- Oxazepam
- Chlordiazepoxide
- Clonazepam: Klonopin
- Alprazolam: Xanax
- Lorazepam: Ativan
- Diazepam: Valium
- Chlorazapate: Tranxene
- Oxazepam: Serax
- Chlordiazepoxide: Librium
142
Name the different stages of alcohol withdrawal.
1. Mild withdrawal
2. Seizures
2. Alcoholic halucinosis
3. DTs
143
When do "mild" alcohol withdrawal sx start?
What are the sx?
6-24 hrs s/p last drink
Anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, (intact orientation)
144
When do alcoholic withdrawal seizures typically start/end?
12-48 hrs s/p last drink
145
When does alcoholic hallucinosis typically start/end?
12-48 hrs s/p last drink
| sensorium intact, stable vitals
146
When do DTs typically start?
48-96 hrs s/p last drink
147
What is the hallmark of DTs?
What are the other sx of DTs?
Disorientation + global confusion
Agitation, fever, tachycardia, HTN, diaphoresis, hallucinations
148
Is alcoholic hallucinosis a type of DTs?
No, DTs are more severe and separate (*DTs potentially life-threatening)
149
What labs should you definitely get in substance use d/o, besides the usual?
- U-tox
- HIV
- Hep A, B, C
(vaccinations for hep A and B to those w/negative serologies)
