Substance use disorder

Question 1

DSM-5 criteria for SUD

Answer 1

Someone who meets 2 criteria for a 12-month period

1. Taken in larger amounts over a longer period of time
2. Persistent desire or unsuccessful efforts to cut down or control use
3. Great deal of time spent in activities necessary to obtain substance or recover from use
4. Craving, strong desire to use
5. Recurrent use in results in failure to fulfill major role obligations
6. Continued despite consistent or recurrent social or interpersonal problems caused
7. Important activities are given up or reduced
8. Recurrent use in situations in which is physically hazardous
9. Continued use despite knowing you have a problem
10. Tolerance
11. withdrawal

Question 2

Absorption of alcohol

Answer 2

10% from stomach, the rest from intestine

Peak 30-90 min

Limited gastric emptying: food slows absorption

Increased acid release (secretagogue): GERD/ulcers

Question 3

Distribution of alcohol

Answer 3

Distributed in total body water

Men dilute ethanol more due to increased total body water

Question 4

Metabolism of alcohol

Answer 4

90% in the liver

1. ADH and Microsomal ethanol oxidizing system
   -MEOS only occurs at high alcohol concentrations
   -CYP2E1 induced–> increased NAPQI
   Ethanol–>Acetaldehyde
2. Acetaldehyde (toxic)–> acetate

Glucuronidation: test to measure alcohol concentration of a longer time

Question 5

Elimination

Answer 5

Zero order kinetics above 10-20 mg/dL

Metabolize 1 drink per hour

Question 6

Step 1 of alcohol metabolism

Answer 6

Alcohol dehydrogenase: liver, brain, or stomach

Men express higher levels of gastric ADH

Question 7

Step 2 of alcohol metabolism

Answer 7

Acetaldehyde dehydrogenase

ALDH1B1 and ALDH2:
-50% of Asians only have ALDH2
-SNP in ALDH2 reduces activity–> ALDH2*2

Heterozygous ALDH2*2:
-Can still consume alcohol
-Flushing, increased temp
-Reduced metabolic activity

Homozygous ALDH2*2:
-Can not still consume alcohol
-Neurotoxicity, stronger hangover, alcohol neuropathy
-Reduced metabolic activity

Question 8

MOA of alcohol

Answer 8

Binds directly (allosteric) GABA-A receptors

NMDA antagonist

Release opioids, Ne, 5-HT, Ach

Question 9

Blood alcohol levels

Answer 9

0.10%=100 mg/dL=100 mg%

Legal driving limit=0.08%=80 mg/dL=80 mg%

Question 10

Actions of alcohol

Answer 10

30-60 mg/dL: euphoria, disinhibition, talkative

60-90 mg/dL: analgesia

80-120 mg/dL: CNS stimulation

100-200 mg/dL: CNS depression

300-500 mg/dL: coma, respiratory depression, death

500 mg/dL: LD 50 for alcohol

Question 11

Cardiovascular effects

Answer 11

Acute: vasodilation
warm, flush, reduced BP, Increase HR

Moderate use: reduced risk of coronary disease

Heavy/chronic: cardiomyopathy, arrhythmias, hypertension, hemostasis

Question 12

Additional effects

Answer 12

hypothermia
gastritis
Appetite stimulant (low doses)
Appetite suppressant (high doses)

Question 13

Long-term effects

Answer 13

Fatty liver and cirrhosis: increased fat metabolism

Vitamin deficiencies: Glutathione, folic acid

Edema
Anemia
LIver cancer

Question 14

Drug interactions with alcohol

Answer 14

CNS depressants: opioids, antipsychotics, antihistamines, sedative

Aldehyde dehydrogenase inhibitors: metronidazole, cephalosporins, sulfonylureas

Acetaminophen
ASA

Question 15

1 IN 8 ADULTS MEET ALCOHOL USE DISORDER

< 8% GET TREATMENT

Answer 15

1 IN 8 ADULTS MEET ALCOHOL USE DISORDER

< 8% GET TREATMENT

Question 16

Stages of alcohol withdrawal

Answer 16

Stage 1: (6-8 hrs) anxiety, tremor, tachycardia, insomnia, n/v, sweating, craving

Stage 2: (24 hrs) auditory and visual hallucinations lasting 1-3 days

Stage 3: (1-2 days) seizures/tonic-clonic after 7-48 hrs after drop in BAC

Stage 4: (4 days) delirium tremens

Mortality associated with DTs 5-15% attribute to arrhythmias, shock, infection, or trauma

Question 17

Risk factors for DTs

Answer 17

Prior hx

of detoxifications

consuming equivalent of 1 pint of whiskey per day for 10 to 14 days prior to admission

symptoms of withdrawal

hepatic dysfunction

Question 18

Fixed dosing/prophylaxis

Answer 18

Chlordiazepoxide +/- Lorazepam PRN

Question 19

Individualized

Answer 19

CIWA < 8: non-pharm
CIWA 8-15: medicate

no liver dysfunction: diazepam, chlordiazepoxide

Liver dysfunction: lorazepam, oxazepam

Question 20

Thiamine!!!!!

Answer 20

100 mg daily IV/IM/PO

Question 21

Wernicke’s encephalopathy

Answer 21

result of thiamine deficiency

give before dextrose-containing fluids

thiamine is co-factor in glucose metabolism, wernicke’s can be precipitated by high glucose loads

Question 22

PHENYTOIN IS NOT EFFECTIVE FOR WITHDRAWAL SEIZURES

Answer 22

PHENYTOIN IS NOT EFFECTIVE FOR WITHDRAWAL SEIZURES

Question 23

Disulfiram

Answer 23

alcoholism

aldehyde dehydrogenase inhibitor

SE: flushing, nausea, vomiting, tachycardia

PATIENTS SHOULD BE ALCOHOL FREE FOR 24 HOURS

Disulfiram reaction up to 14 days after d/c

Question 24

Acamprosate

Answer 24

renal elimination, monitor renal function, avoid in renal impairment

Suicidality warning: side effects also include diarrhea, nausea, depression, anxiety

Question 25

Naltrexone

Answer 25

Decreases binge drinking, helps increase time between drinking days

Elevated LFTs common, monitor baseline and routinely

Need to evaluate pain management needs, patient should have wallet card to be able to tell emergency providers that they are taking this

Best efficacy in 118G SNP

Warning for injection site reactions

Question 26

Fomepizole

Answer 26

alcohol dehydrogenase inhibitor

ethylene glycol, MeOH poisoning

Effects: slow formation of formaldehyde and toxic metabolites