18. Substance Use Disorders

what are the components of the CIWA?

components of the COWS

alcohol acute effects

alcohol chronic effects

symptoms of alcohol withdrawal

alcohol complications

treat

treatment of alcohol use disorder

what meds help with overdose?

what meds help with withdrawal?

what meds help with maintenance (craving)

risks of withdrawal

key interventions for withdrawal

schedule 1

high potential for abuse. NO acceptable medical use

examples of schedule 1

LSD, heroin

schedule 2

high potential for abuse and considered dangerous. available only by prescription

schedule 2 examples

methadone, Demerol, methylphenidate for ADHD

schedule 3

low to moderate potential for misuse

schedule 3 examples

testosterone, acetaminophen/codeine (Norco) buprenorphine (for opiate addiction)

schedule 4

low risk. need prescription

schedule 4 examples

benzos. alprazolam, lorazepam

schedule 5

contain limited quantities of narcotics. for treatment of diarrhea, coughing, pain

genetic risk factors for SUD?

strong family correlation! twin studies 70-80% linked for opiates and cocaine

neurochemical risk factors for SUD

levels and sensitivity of opioid receptors, GABA, dopamine

environmental risk factors for SUD

chronic stress, poverty, lack of parental supervision, poor education, impaired support, peer influence, ACEs

DSM for SUD

4 categories of sx

1. impaired control

2. social impairment

3. risky use

4. physical effects (intoxication, tolerance, withdrawal)

caffeine excess use

not an official disorder BUT intoxication and withdrawal are in the DSM-5

tobacco withdrawal treatment

behavioral therapy, nicotine replacement therapy

ex: breathe through a straw to mimic the behavior. transdermal patches

what antidepressant for tobacco maintenance?

bupropion. seizure risk - NO if seizure, stroke, and TBI. take it in the morning. appetite suppressant. can cause anxiety

Varenicline AE

BLACK BOX for psych effects. mood change, suicidal ideation, crazy dreams. take them off the med if they have these things

also insomnia, N/V, depression

varenicline for tobacco maintenance

mimics nicotine. reduces craving and withdrawal

what to teach the pt on Varenicline

take AFTER a meal. if you smoke, it will have less of an effect. contraindicated for truck drivers and pilots 

what psych illness does marijuana use increase the risk for?

schizophrenia

symptoms of cannabis intoxication?

heightens sensations. time slows. red eyes, increased appetite, tachycardia. motor skills impacted for 8-12 hours

cannabis withdrawal symptoms - mental and emotional

irritability, anger, aggression, anxiety, restless, depressed, insomnia, decreased appetite

cannabis w/d sx - physical

abdominal pain, shakiness, sweating, fever, chills, headache

when can cannabis withdrawal sx show up?

within 1 week of cessation

treatment for cannabis use disorder

abstinence and support! therapy (individual, group, family), short term antianxiety, SSRI if depressed

difference between cannabinoids and cannabis?

cannabinoids are synthetic chemicals. standard drug tests can NOT easily detect cannabinoids and they are easily accessible 

mental status concerns with cannabinoids

can disconnect user from making appropriate decisions. this lingers for a couple days after use and can cause permanent dementia if used a LOT

reported effects of cannabinoids

elevated mood, relaxation, altered perception, PSYCHOSIS

• anxiety, confusion

• paranoia, hallucination

• rapid heart rate, vomiting

• violent behavior, suicidal thoughts

hallucinogens are associated with what psych effects?

flashbacks, panic attacks, psychosis ,delirium, mood and anxiety disorders

phencyclidine (PCP) intoxication presentation

belligerent, assaultive, unpredictable. UNSAFE and can not be talked down

how to handle PCP intoxication?

keep yourself safe first and the pt safe second. they will probably need restraint and calming medications like benzos

sx unique to hallucinogen intoxication

synesthesia, paranoia, depersonalization/derealization, veryyyy large pupils, sweating

what is unique about hallucinogen withdrawal?

brain can have flashbacks and enter another state of intoxication. this one is not as severe and can happen YEARS after they took the substance

how long can hallucinogen withdrawal last?

can impair individual from normal functioning for weeks to months to years

psychological characteristics of inhalant intoxication, dose-dependent

small doses - disinhibition, euphoria

large doses - fearfulness, hallucinations, distorted body image

physical sx of inhalant intoxication

nausea, anorexia, nystagmus, depressed reflexes, diplopia (double vision)

age range most common for inhalants

12-17. concerned that they’ll “graduate” to harder drugs

stimulant use disorder - 2 or more of what sx?

chest pain, arrhythmias, HTN or HoTN, tachy/bradycardia, respiratory depression, pupil dilation, sweating, chills, NV, weight loss, psychomotor agitation or retardation, weakness, confusion, seizures, coma

tx of stimulant use disorder

manage cardiac effects! monirot for arrhythmia. caution with beta blockers and cocaine

when can stimulant w/d start?

a few hours to several days

sx of stimulant w/d

tiredness, vivid nightmares, increased appetite, sleep disturbance, psychomotor slowing or agitation

depression and suicidal thoughts

tx for stimulant w/d

amphetamines go inpt

cocaine go outpt since no physiological sx that require inpt

how do stimulants work and what do they do?

increase dopamine and norepinephrine. they increase attention, reduce impulsivity, restlessness, and distractability

stimulants contraindicated with WHAT?

SUD, CV issues, anxiety, psychosis, MAOIs,

dextroamphetamine (Adderall, Vyvanse) treats what?

ADHD and binge eating disorder (reduces risk of relapse)

side effects of dextroamphetamines

dry mouth, insomnia, decreased appetite, increased heart rate, jittery, anxiety, constipation

methylphanidate (Ritalin) medication interactions

increases levels of warfarin

phenytoin phenobarbital - sedates and causes respiratory depression

intoxication sx of sedatives, hypnotics, and antianxiety meds

slurred speech, incoordination, unsteady gait, nystagmus, impaired thinking (slow)

overdose tx for sedatives, hypnotics, and antianxiety meds

gastric lavage, activated charcoal, monitor and control v/s, keep them awake if they are conscious

if unconscious, start IV and intubate. give FLUMAZENIL

flumazenil - what to give and how to give

IV med to reverse benzodiazepines. give it over 30 seconds and wait 1 minute between doses 

.2mg to .3 to .5. repeat .5 as needed. MAX is 3mg/hour

if the pt does not respond within the first 5 mins, it’s not a benzo problem 

withdrawal sx of sedative, hypnotic, and antianxiety meds

tremors, insomnia, psychomotor agitation, anxiety, grand mal seizure

how to detox from benzos?

at the HOSPITAL with a PROVIDER. gradually taper or use an anticonvulsant.

what is binge drinking?

women 4+ drinks within 2 hours

men 5+ within 2 hours

what is heavy drinking?

women 8+ in 1 week

men 14+ in 1 week

DSM criteria for alcohol use disorder

problematic pattern of use leading to clinically significant impairment or distress. 2 or more of select sx in a 12 month period

DSM criteria for alcohol tolerance

need for increased amounts of alcohol to achieve intoxication/desired effect. diminished effect with continued use of the same amount of alcohol

DSM criteria for alc w/d

characteristic withdrawal syndrome. taken to relieve/avoid withdrawal problems

how many drinks for a bac of 0.08g/dL and what symptoms show up?

4 drinks

poor muscle coordination, altered speech and hearing, impaired judgement, poor self control, decreased reasoning

how many drinks for 0.15g/dL blood alcohol level and what sx?

6 drinks. vomiting (unless high tolerance) and major loss of balance

how many drinks for 0.30g/dL and what sx?

more than 10. reduction of body temperature, blood pressure, respirations, sleepy, amnesia

how many drinks for 0.40g/dL BAC and what sx

impaired vitals and possible death. some alcoholics will be awake and talking at this point while others might be in a coma

classic sign of alcohol w/d

tremors/shakes/jitters begin 6-8 hours after cessation

mild to moderate sx of alc w/d

increase in bp, pulse, temp

most important question to ask pt going through alcohol withdrawal and why?

when was your last drink?

certain sx show up and different points so you need to know what point they’re at

ex) shakes begin in 6-8 hours, psych sx begin within 8-10, and w/d seizures can start at 12 hours 

what are the first signs of delirium tremens? what do we do if we see this?

altered LOC. hallucinations, confusion, illusions

we have to get a head start. there is a specific protocol to prevent dt and we treat with benzos

who is at greater risk of developing delirium tremens?

alcoholics with liver disease, pancreatitis, poor health

what are Wernicke’s encephalopathy and Korsakoff’s syndrome caused by?

thiamine deficiency!!! vitamin B1

Wernicke’s encephalopathy sx

altered gait, confusion, ocular motility abnormalities, sluggish reaction to light and unequal pupil size

how to manage Wernicke’s encephalopathy?

it responds to large doses of IV thiamine. it is acute and reversible. it might clear up and it might progress to Korsakoff’s syndrome

Korsakoff’s syndrome time

it’s chronic and has a recovery rate of only 20%

treat with thiamine for 3-12 months but most never recover

what is the most life threatening chronic alcohol use physical effect?

esophagitis and esophageal varices. distended veins cause a risk for bleeding and if they rupture it is a medical emergency

4 questions of CAGE

1. have you ever felt the need to cut down on drinking?

2. are people annoyed by your drinking?

3. have you ever felt guilty about your drinking?

4. have you ever had a drink in the morning?

biggest part of family assessment for a pt who has alcohol use disorder

codependence. are they overly responsible for the family member and excluding their own needs?

key questions in a patient assessment for alcohol use

do you want to stop? why? what’s your motivation? how can we get you there?

what to take into account when planning for a pt with SUD

recognition of the problem and the motivation to change

physical sx of opioid w/d

sweating, restlessness, large pupils, bone or joint aches, goosebumps, GI upset, tremor, yawning, runny nose