Topic 11: Substance Use Disorders (Ch 22)

caffeine

the most widely used psychoactive substance, and while not an official use disorder, excessive use can cause intoxication, overdose, withdrawal, and is associated with psychiatric problems including bipolar, eating disorders, and sleep disorders

Recent consumption of a high dose more than 250 mg in as early as 15 minutes and can last for 6 hours

when does intoxication of caffeine occur

• restlessness

• nervousness

• excitability

• agitation with physical symptoms such as diuresis, GI upset, muscle twitching, tachycardia, and arrhythmias

what are the s/s of caffeine intoxication

• lethal doses are rare on coffee/tea but can be caused by energy drinks, OTC decongestants, and bronchodilators

• fever

• tachycardia or bradycardia

• HTN initially, followed by hypotension

• grand mal seizures

• respiratory failure

• pupillary mydriasis (dilation)

• muscular rigidity

• hyperreflexia

• N/V

• disorganized thinking

• agitation

• delusions

• hallucinations

• seizures

what are the s/s of a caffeine overdose

• generally supportive care

• hydration

• gastric lavage

• activated charcoal

• beta blockers for tachycardia

• vasopressors to maintain BP without worsening tachycardia

what is the treatment for caffeine overdose

• not associated with serious medical issues/doesn’t need intervention

• HA

• drowsiness

• irritability

• poor concentration

• flu like S/S: N/V, muscle aches

• occurs within 12-24 hours of last dose

• peaks in 24-48 hours

• resolves within 1 week

what are the s/s of caffeine withdrawal

cannabis/marijuana

• 3rd most commonly used psychoactive drug in the US that is primarily smoked but can be ingested

• contains THC and CBD, but CBD alone does not cause intoxication

• has both depressant and hallucinogenic properties

• desired effects are euphoria, relaxation, and detachment

• euphoria

• relaxation

• panic attacks

• anxiety

• psychosis

• heightened sensation, distorted sensory perception

• slowing of time

• impaired balance and coordination

• slowed motor responses and reaction time

• conjunctival redness

• increased appetite

• impaired learning and memory

• dry mouth

• tachycardia

• depersonalization and derealization

• hallucination may occur with/without delirium

what are the s/s of cannabis/marijuana intoxication

• starts about 1 week after use

• irritability

• anger

• aggression

• anxiety

• restlessness

• depressed mood

• insomnia

• abdominal pain

• sweating

• fever

• HA

• decreased appetite

• disturbed sleep

what are the s/s of cannabis/marijuana withdrawal

• lethargy

• anhedonia

• difficulty concentrating

• loss of memory

• amotivational syndrome

• weight loss

what are the long term effects of cannabis/marijuana

• abstinence and support

• hospitalization or outpatient

• individual, family, group therapy

• antianxiety meds for short term relief of withdrawal symptoms

• antidepressants for underlying anxiety and depression

what is the treatment for cannabis/marijuana withdrawal

hallucinogens

• intoxicants that cause significant disturbance in reality and are associated with flashbacks, panic attacks, psychosis, delirium, and mood/anxiety disorders

• consists of natural and synthetic substances

• schedule 1

• no medical use and high abuse potential

• ie. LSD, mescaline, psilocybin (magic mushroom)

• altered states of perception and feeling

• hallucinations, illusions

• nausea

• increased body temp, HR, BP, heart palpitations

• loss of appetite

• sweating

• sleeplessness

• numbness

• dizziness

• weakness

• tremors

• impulsive behavior

• rapid shifts in emotion

• flashbacks

• paranoia

• intensifying perceptions

• impaired judgment

• depersonalization/derealization

• synesthesia: seeing sounds or hearing colors

• dilated pupils, blurry vision

• uncoordinated movements

what are the s/s of hallucinogen intoxication

• talk the patient down

• safety

• physical retraint may be necessary

• antipsychotics like Haldol or a benzo like Valium may be used short term in severe cases

what is the treatment for someone on hallucinogens

reexperiencing perceptual symptoms that were experienced while intoxicated, which is distressing and impairs the individual from normal functioning for weeks, months, or even years

what are the s/s of hallucinogen withdrawal

PCP, ketamine, salvia

what are the dissociative drugs

• medical emergency with violent SE

• nystagmus

• HTN, tachycardia

• higher pain threshold

• ataxic

• unclear speech

• sensitivity to sound

• feeling of being separate form one’s body and environment

• impaired motor function

• analgesia

• psychosis

• aggression

• violence

• loss of coordination

• hallucinations

• anxiety, tremors

• numbness

• nausea

• belligerent

• assaultive

• impulse, unpredictable

• hyperthermia

• seizures

what are the s/s of PCP intoxication

• Management is the most supportive care

• Patients cannot be talked down and may require restraint

• benzos may be given IV or IM to calm them down

• Mechanical cooling may be needed for severe hyperthermia

what is the treatment for PCP

ketamine

a dissociative drug that has hallucinogenic, psychedelic, and dissociative properties that is used therapeutical for treatment resistant depression and cautiously as a sedative/anesthetic in some medical and veterinary settings, but is highly regulated

• Dreamlike state leads to anterograde amnesia and complete compliance of the victim

• confusion

• paranoia

• delirium

• combative

• drooling

• hallucinations

• respiratory depression and arrest

• death

• anxiety, tremors

• numbness

• nausea

what are the effects of ketamine

airway maintenance and anticholinergics such as atropine and benzos

what is the treatment for ketamine

inhalants

volatile hydrocarbons (toxic gases) that are inhaled through the nose or moth and go into the bloodtream via sniffing, bagging, and/or huffing

include:

• solvents for glues/adhesives

• propellants in aerosol paints, hair sprays, and shaving cream

• pain thinners and correction fluids (white out)

• gasoline and propane

• cleaning fluids

Generally are not used long term, but if they are can cause major issues and sudden sniffing death syndrome from heart arrhythmias

• small doses: euphoria, disinhibition

• high doses: illusions, hallucinations, distorted body image, fearfulness, apathetic behaviors, lower social and vocational functioning, impairment in judgement and making decisions, aggression

• nausea, loss of appetite, slowed reflexes, double vision

• long term: stupor, LOC, amnesia, delirium, dementia, and psychosis, which results in seizures, irreversible brain damage, and death

what are the s/s of inhalant intoxication

• usually doesn’t require any

• treat cardiac issues, bronchospasms, and coma if they occur

• Short-term Haldol use may help with severe symptoms

what is treatment of inhalant use

opioid use disorder

Chronic, relapsing disorder that commonly includes misuse of heroin and oxycodone, but others include hydrocodone, morphine, fentanyl, and codeine

• psychomotor retardation

• drowsiness

• slurred speech

• altered mood (withdrawn to elated)

• memory and attention impairment

• pinpoint pupils

• decreased BS, RR, BP, and HR (may be normal)

• skin issues may occur with IV use

• sedation

• head nodding

• euphoria

• analgesia

• calmness

what are the s/s of opioid intoxication

• main three: coma, pinpoint pupils, respiratory depression

• unresponsive

• slowed breathing

• hypothermia

• hypotension

• bradycardia

• death can occur due to respiratory arrest

what are the s/s of opioid overdose

• maintain breathing and establish an airway

• aspirate any secretions

• may need mechanical ventilation

• Narcan intransally, IM, SQ, or IV: is short acting so may need to be repeated, step back patient will come up swinging

what is treatment for opioid overdose

• mood disturbances

• body aches, bone and muscle pain

• anxiety

• tachycardia, HTN, hyperthermia

• insomnia

• diaphoresis

• hyperreflexia, muscle spasms

• N/V, abdominal cramps

• runny nose

• dilated pupils

• yawning

• diarrhea

• lacrimation

• rhinorrhea

• pupil dilation

• piloerection (goose flesh)

• males may experience sweating and spontaneous ejaculation

what are the s/s of opioid withdrawal

methadone (Dolophine)

what is the treatment for opioid withdrawal

methadone (Dolophine)

opioid agonist that blocks the cravings for opioids and is used for detoxification and is the most effective, will eventually need to withdraw from it as well

Clonidine (Catapres)

• alpha agonist antihypertensive that is used to reduce symptoms and decrease anxiety by blocking NTs that trigger SNS activity

• easy sweating, hot flashes, watery eyes, restlessness, anxiety, and may shorten detox process

• effective when combined with naltrexone

lofexidine

• An alpha agonist used for the mitigation of opioid withdrawal symptoms during abrupt discontinuation, but is expensive

• allows for people to withdraw at home in a few days rather than a week.

buprenorphine (Subutex)

• opioid partial agonist that produces euphoria or respiratory depression but much milder than drugs like heroin or methadone

• blocks the S/S of opioid withdrawal/maintenance

• Schedule 3 drug, so risk of addiction

• SE: N/V, constipation, insomnia, irritability, fever

• must have abstained from opioids for 12-24 hours and be in the early stages of withdrawal

naltrexone (ReVia, Vivitrol)

opioid antagonist that blocks the euphoric effects of opioids and prevents intoxication

• Vivitrol: injectable long-acting form that is used for the preventing of relapse following detox, given IM once a month

• SE: GI distress, muscle cramps, dizziness, sedation, appetite disturbances, injection site reactions like pain, swelling, bruising, cellulitis, induration, abscess, and necrosis

Buprenorphine, naltrexone, and methadone

reduce cravings in maintenance therapy

• individual therapy

• CBT

• family therapy

• social skills training

• support groups

• must be highly motivated

what psychological treatments are available for opioid use disorder

• slurred speech

• unsteady gait

• impaired thinking

• incoordination

• nystagmus

• coma

• inappropriate aggression and sexual behavior

• mood fluctuation

• impaired judgement

what are the S/S of CNS depressant (alcohol, benzos, barbiturates) intoxication

• autonomic hyperactivity

• tremors

• psychomotor agitation

• anxiety

• insomnia

• grand mal seizures

what are the S/S of CNS depressant (alcohol, benzos, barbiturates) withdrawal

• gradual reduction of benzos to prevent seizures and other S/S

• can be aided with phenobarbital (long-acting barbiturate)

what are the treatmetns of CNS depressant (alcohol, benzos, barbiturates) withdrawal

• CV or respiratory depression

• coma

• shock

• convulsions

• death

what are the S/S of CNS depressant (alcohol, benzos, barbiturates) overdose

• if awake, keep awake to prevent loss of consciousness

• if unconscious, establish IV fluid line

• maintain airway with use of endotracheal tube and mechanical ventilation if needed

• induce vomiting

• administer activated charcoal

• gastric lavage

• check VS every 15 minutes

what are the treatments of CNS depressant (alcohol, benzos, barbiturates) overdose

• clear the airway, insert an endotracheal tube

• admin IV fluids

• gastric lavage with activated charcoal

• frequent VS check, even once stable, due to potential for shock and cardiac arrest

• implement seizure precautions

• hemodialysis may be needed

• if benzo overdose: flumazenil (Romazicon) IV

what are the interventions if someone who OD on CNS depressants goes into a coma

flumazenil (Romazicon) IV

what is the treatment for a benzo overdose

stimulants

second to cannabis as the most widely used illicit substance in the US that includes amphetamine, cocaine, and others that produce euphoric moods and high energy

• elation, euphoria, social

• hypervigilant, sensitive, anxious, tense, angry

• increased energy and socialization

• decreased appetite

• dilation of pupils

• “cocaine bugs” (skin sensation)

• dryness of nasal cavity if snorted

• excessive motor activity

• variations in VS

• chest pain, arrhythmias, high/low BP, tachy/bradycardia, respiratory depression

• sweating, chills, N/V, weight loss

• psychomotor agitation/retardation

• weak

• confused, paranoia

• violent behavior

• insomnia

• coma

• seizures

what are the s/s of stimulant intoxication

• occurs within a few hours to several days

• tired, vivid nightmares

• fatigue, anxiety, irritability

• poor concentration

• psychomotor retardation

• paranoia

• drug craving

• insomnia or hyperinsomnia

• increased appetite

• functional impairment

• depressed and SI

what are the s/s of stimulant withdrawal

• Inpatient setting is best

• individual, family, and group therapy

• Antipsychotics may be used for a few days

• diazepam may help with agitation and hyperactivity

• Antidepressants can help with depression and anxiety during and after withdrawal is complete

• 1-2 weeks of cocaine require no inpatient care as no drugs reduce S/S

what are the treatments of stimulant withdrawal

cocaine and crack

• extracted from the leaf of the coca bush

• when smokes take effect in 4-6 seconds and produce a fleeting high lasting 5-7 minutes

• main effects are anesthetic and stimulant effects

• depression

• paranoia

• lethargy

• anxiety

• insomnia

• N/V

• sweating

• chills

what are the s/s specific to the withdrawal of cocaine and crack

• crash phase: anxiety, depression, cravings peak, and agitation; lasts 4 days

• second phase: no motivation, anhedonia; lasts for 10 weeks and relapses if likely

• third phase: intermittent craving; undetermined length of time

what are the phases of withdrawal of cocaine and crack

methamphetamines

• stimulants that are highly addictive and have neurotoxic effects

• S/S resemble the psychosis of schizophrenia

• Chronic use can lead to Parkinson like S/S

• prolonged use can cause cracked teeth, skin infections, stroke, lung disease, kidney/liver damage, and death

tobacco

substance that is highly addictive in any form (smoked, chewed, inhaled), socially acceptable, and chronic and relapsing that often results in serious illness

• increased BP and HR

• chronic lung disease

• CV disease

• Stroke

• cancer of the mouth, pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, bladder, and AML

• adverse pregnancy outcomes

what are the effects of tobacco on the body

heroin

opioid that causes euphoria, drowsiness, impaired coordination, dizziness, confusion, nausea, sedation, feelings of heaviness in the body, and slowed/arrested breathing, which can cause constipation, endocarditis, hepatitis, HIV, addiction, and fatal overdose

• anxiety

• aggression

• irritability

• weight gain

• insomnia

• difficulty concentrating

• restlessness

• depression

• Within days of stopping, HR decreases by 5-12 bpm

• with a year of stopping weight increases by 4-7 lbs

what are the s/s of tobacco withdrawal

• behavioral therapy to teach how to recognize and respond appropriately to cravings

• hypnosis

• nicotine replacement therapies: gum, lozenges, nasal sprays, inhalers, patches

• bupropion (Zyban) reduces cravings and symptoms

• Varencline (Chantix): mimics effects of nicotine, reducing craving and withdrawal, and blunts effects if smoking is a result

what does treatment for tobacco withdrawal and prevention of relapse include

e-cigs/vaping

• was once advertised as a safe alternative to cigs, but recent reports indicate otherwise

• does not prevent people from starting to use cigs

• increases death in youth/young adults from lung and brain injury

• leads to cig use and addiction

• contaminants cause chemical irritation and allergic/immune responses

• S/S: SOB, chest pain, difficulty breathing

club drugs

simulated amphetamines that are “designer” drugs with a combo of the worst possible side/adverse effects of stimulants and hallucinogens; include MDMA, MDA, and MDE

MDMA

club drug that causes mild hallucinogenic effects, increased tactile sensitivity, empathetic feelings, lowered inhibition, anxiety, chills, sweating, teeth clenching, and muscle cramping, which leads to sleep disturbances, depression, impaired memory, hyperthermia, and addiction