Substance Use/abuse

Question 0

Substance abuse epi

Answer 0

• more common in men
• in general lower income good predictor (alcohol abuse more common in educated urban)
• script opioids and heroine
• of co-morbid conditions, anti-social personality disorder 80%

Question 1

Most common illicit drug

Answer 1

Cannabis

Question 2

Biology of addiction

Answer 2

• dopaminergic
• nucleus acumbens
• social attachments: loners, distant from parents, abuse all increase
• rapid onset = more addicting (greater high)

Question 3

ALDH2

Answer 3

• polymorphism resulting in lower alcohol metabolism (less alc dehyd)
• worse hangovers
• associated with lower rates of alcoholism; higher metabolic rates assoc with hire alcoholism

Question 4

Alcohol cross tolerance

Answer 4

Benzos
Barbiturates
- all three withdrawal can kill you

Question 5

AST/ALT

Answer 5

• last call for alcohol: 21 typical ratio in suspected EtOH: 2/1
• in general enzymes all increase, ions/nutrients decrease
• thiamin BEFORE glucose

Question 6

CDT (carbohydrate deficient transferrin)

Answer 6

• highly sensitive and specific for excessive EtOH consumption

Question 7

GGT (and false positive)

Answer 7

• fairly specific for alcohol abuse

- not very good for detecting relapse and can be elevated by ibuprofen, phenobarbital, and Dilantin

Question 8

MCV (mean corpuscular volume)

Answer 8

• large RBCs due to malnutrition and due to alcohols toxic effect on marrow
• combined GGT and MCV are highly suggestive of alcohol abuse

Question 9

Depressant effect of alcohol

Answer 9

• initially may produce euphoria

- eventually depresses CNS and psychological worsens psychological depression

Question 10

Wernicke-korsakoff

Answer 10

• wernickies: more acute phase
  ~ opthalmoplegia; nystagmus, Diplopia
  ~ ataxia
  ~ memory impairment, apathy (confused state)
  ~ 90% progress from wernickies to Korsakoffs
• Korsakoffs: chronic effects
  ~ degeneration of mammillary bodies, hypothalamus
  > loss of STM, confabulation
• TREAT: thiamin before glucose (be generous with treatment)

Question 11

Alcohol withdrawal (time frame)

Answer 11

• begins 6-8 hours, peaks at 24-48, resolves at 4-5 days

- severe symptoms are uncommon (5%)

Question 12

Complicated EtOH withdrawal

Answer 12

• usually includes hallucinations (usually auditory, visual and tactile rare but possible)
• occurs in presence of clear sensorium
• last ~ 1 week
• non-life threatening

Question 13

EtOH withdrawal seizures

Answer 13

• 6-48 hours after last drink
• usually tonic-clonic (can progress to status epilepticus)
• benzos first line

Question 14

Delirium tremens

Answer 14

• life threatening
• normal withdrawal, includes delirium and autonomic dysfunction
• supportive care, potentially sedation and seclusion

Question 15

Uncomplicated withdrawal: 4 primary symptoms

Answer 15

• dysrythmia
• pancreatitis
• TB
• GI bleeds
• treat early and often w/ thiamin and folate

Question 16

Complicated withdrawal trt

Answer 16

• Valium load 20mg q hour x3 or till they sleep

- diazepam (valium)/ chlorodiazepoxide (Librium) long acting preferred except in elderly (use oxazepam or lorazepam)

Question 17

Addiction treatment

Answer 17

• disulfiram: aversive (NO EtOH -> instant severe hangover)
• naltrexone: not in liver dysfunction (monitor lfts), can precipitate withdrawal
• acamprosate: hig dose = poor compliance; safe in liver dysfunction
• topiramate: lots if mood/metabolic side effect

Question 18

Benzo intox/withdrawal

Answer 18

• benzos are EtOH in a pill
• OD with benzos rarely fatal, combo mush more dangerous
• effects are similar: day 1- anxious, restless, coarse tremor and auto hyper-arousal; day 2-3: seizures

Question 19

Withdrawal trt: benzos, barbs, EtOH

Answer 19

• barbiturates: trt with barbs
• benzos: trt with benzos or barbs
• EtOH: trt with all three

Question 20

Opiate addiction

Answer 20

• withdrawal rarely fatal, only in infants
• OD can be fatal
• most common in antisocial personality disorder
• relapse rates really high
• opiates mixed effect, but primarily parasympathetic
• respiratory depression danger/fatality

Question 21

Opiate withdrawal/OD

Answer 21

- OD is hypercholinergic effect 
   ~ main issue is airway protection 
   ~ naxalone -> withdrawal 
- withdrawal is anticholinergics effect 
   ~ symptomatic trt: 
    > Clonadine: autonomic symptoms
    > Benadryl: rhinorrhea/itching
    > NSAIDs: pain
    > promethazine: N/V
    > loperamide: diarrhea/cramps 
- methadone for chronic trt (bupropion alternative)

Question 22

Consideration when using naltrexone

Answer 22

• Pt must be opioid free for 7 days to avoid withdrawal

Question 23

Meth v. Cocaine

Answer 23

• meth:
  ~ man made, blocks reuptake and induces release, 8-24 hr 1/2L, neurotoxic in chronic users
• cocaine:
  ~ natural, only blocks reuptake, 23-30 minute high, 1 hour 1/2L, no evidence of neurotoxicity

Question 24

- tachycardia - HTN - mydriasis - diaphoresis - NV - anorexia - psychomotor agitation - transient psychosis - hypersexuality - bruxism

Answer 24

Stimulant intoxication

Question 25

- anxiety - dysphoria - lethargy/fatigue - HA - muscle cramps - hunger - profuse sweating

Answer 25

Stimulant withdrawal

Question 26

Stimulant treatment

Answer 26

- usually withdrawal/OD is self limiting | - symptomatic trt: benzos for agitation, antipsychotics for psychosis

Question 27

Hallucinogens effects

Answer 27

- Sympathomemetic effect - bad trips can be permanent in chronic users - anticipating bad trip -> more likely

Question 28

Hallucinogen e.g.

Answer 28

- LSD: rapid onset, synesthesia - MDMA: (ex) strong feelings of attachment, euphoria, altered time perception, hyperpyrexia (esp with PMA and PMMA) - PCP: dangerous, vertical nystagmus (can cause horizontal nystagmus but vertical is sp. for PCP) 30 minute peak, aggression,

Question 29

PCP trt

Answer 29

- benzos/antipsychotics: agitation - phentolamine: for HTN - hydration (rhabdo is significant risk) - excretion most effective trt: acidifying, diuretics

Question 30

Cannabis

Answer 30

- red eyes, dry mouth, munchies, ortho HoTN, tachy, depersonalization/derealization, psychosis, euphoria - amotivational syndrome - withdrawal may or may not exist: benzos for anxiety

Question 31

Accelerant issues

Answer 31

- only one to cause heavy metal poisoning, NM tox, brain damage - can cause sudden death from arrythmias - resp. Comp, immun. comp

Question 32

Nicotine dependance/withdrawal/trt (timeframe)

Answer 32

- dependance is essentially the necessary conclusion - withdrawal: 1 hour after last cigarette, peaks at 24 can last weeks/months - trt: replacement, intervention: bupropion, varenicline anti-NM receptor

Question 33

Caffeine considerations (lethality, co-morbidities)

Answer 33

- greater that 1g/day can put you in coma - associated with co-morbidities in chronic use ~ HTN, exacerbation of fibrocystic disease in women ~ anxiety

Question 34

fibrocystic disease in women

Answer 34

- co-morbidity of nicotine use