Substance Abuse Disorder

The RATE of increases of dopamine levels.

• Ex. IV cocaine reaches the brain faster and dopamine levels rise quicker than oral

What is the degree of reinforcement of drug use linked to?

Diagnostic criteria for SUD

Mild: 1-3

Moderate: 4-5

Severe: 6+

Alcohol

barbiturates

BZDs

Cannabinoids

Hallucinogens

Nicotine

Opioids

Stimulants

What are the drugs with potential for SUD?

Screening

-Helps assess the severity of substance use and aids to objectively identify a level of treatment for each patient

Brief intervention

Centers on behavioral changes by increasing awareness to the problem at hand.

Referral to Treatment (RT)

Provides patients the opportunity for an evaluation by trained personnel and referral to appropriate level of treatment.

1.) Reducing substance abuse or achieving a substance-free life.

2.) Maximizing multiple aspects of life functioning

3.) Preventing or reducing the frequency and severity of relapse.

What are the three generalized goals for all substance abuse treatment programs?

(initially, the patient needs to be detoxed from the substance → managed medically)

Alcohol

-Most common substance that Americans use to alter their state of mind

-Increases the risk of certain conditions:

• Stroke

• HTN

• Depression

• Esophagus cancer

• Cirrhosis of the liver

-CNS depressant that has similar effect as barbituates and BZDs

-Increases the actions of GABA and inhibits the release of Ach.

Metabolic syndrome

Wernicke’s encephalopathy

What are two conditions that can arise from AUD?

Metabolic Syndrome

-Abdominal obesity, hyperglycemia, high cholesterol, and high blood pressure

• Exacerbated by the cell damage and higher caloric intake in patients consuming large amounts of alcohol.

-Thiamine deficiency occurs due to decreased absorption and poor diet

Wernicke’s Encephalopathy

-Acute life-threatening neurological condition characterized by a triad of nystagmus, ataxia, and confusion. can result from administering glucose in the absence of thiamine.

-ALL heavy alcohol users need thiamine prior to any nutritional intervention.

-BANANA Bag → D5NS + Thiamine 100mg + Folate 1mg + MVI + Mag. Sulfate 2gm

Category of drinking

-Moderate drinkers → 1 drink/day for females, 2 for males

-Heavy Drinkers → 3 drink/day for females; More than 4 for males

2-4 drinks/hour → BAC 0.08-0.1% (legal limit is 0.08%)

Alcohol withdrawal

-Symptoms may appear 6-12 hours after discontinuation of alcohol but can start 1-3 days later and may last up to a week.

-Mild symptoms: (managed outpatient if no history of delirium tremens or seizures)

• Anxiety, sweating, restlessness, insomnia

-Moderate Symptoms:

• Mild symptoms + increased blood pressure/HR

• Confusion

• Mild hyperthermia

-Severe Symptoms:

• Moderate symptoms + hallucinations

• impaired attention

• Seizures and delirium tremors.

Delirium Tremens (DT)

-Characterized by a rapid onset of psychological/neurological changes, hallucinations, and sympathetic overdrive.

-Considered the worst form of alcohol withdrawal, presents like delirium

Chlordiazepoxide

Diazepam

Lorazepam

Oxazepam

What are the BZDs that can be used to treat AUD?

Acamprosate

Disulfiram

Naltrexone

What are the 3 main drugs used for AUD?

Acamprosate (campral)

USE: moderate-severe AUD, decreases the severity of withdrawal symptoms.

MOA: GABA agonist/Glutamate antagonist.

-Three times daily dosing (compliance issues)

-Contraindicated in renal impairment and sulf allergies.

AE:

• Diarrhea, nausea

• Insomnia

• Puritis, asthenia

• Anxiety, depression

• HTN

Naltrexone (REvia & Vivitrol)

-USE: AUD and OUD

MOA: pure opioid antagonist with high affinity for the mu opioid receptor which may block alcohol activity.

• Blocks the euphoria of alcohol, making it less rewarding.

-Available PO (daily) or IM (every 4 weeks)

• must d/c 30 days prior to surgery

AE:

• Exacerbation of withdrawal (must be free for 7 days)

• Nausea, headache

• injection site reactions.

Contraindications:

• Use of opioids/alcohol in the past 7 days

• Acute opioid withdrawal

• Failed naloxone challenge

• Positive urine opioid screen

• Acute hepatitis or liver failure.

Disulfiram (antabuse)

USE: AUD deterrent → produces unpleasant effects when taken with alcohol.

-Reaction can occur with even small amounts of alcohol (mouthwash, cough syrups, sauces)

-Metallic or garlic-like taste

Contraindications:

• Cardiac disease

• severe respiratory or renal disease

• severe hepatic dysfunction

• Poor impulse control

• Metronidazole and ketoconazole

Varices

Enlargement of splanchnic vessels in the esophagus and stomach, risk of rupture and profuse GI hemorrhage.

Ascites

Buildup of fluid in the peritoneum

Spontaneous bacterial peritonitis (SBP)

Infection of the peritoneal space from most likely increased intestinal permeability → bacterial translocation from gut to peritoneal space.

Hepatorenal Syndrome (HRS)

Profound reduction of blood flow to the kidneys → Prerenal acute or subacute kidney injury

Hepatic Encephalopathy

Neuropsychiatric complication of cirrhosis from ammonia accumulation crosses BBB causing transient damage to astrocytes and neurons.

-Symptoms range from mild inattention and agitation to coma and death.

Nicotine replacement therapy

Varenicline (Chantix)

Bupropion (Zyban)

What are 3 approaches for treatment of tobacco use disorder?

Nicotine replacement therapy

-Chewing gum, lozenges and patches

-Mitigates nicotine withdrawal

Bupropion (Zyban)

-Atypical antidepressant

• The ability to block the reuptake of dopamine may contribute to effectiveness.

-Decreases the urge to smoke, and reduces withdrawal symptoms.

-Start taking 1 week before your quit date.

AE:

• Insomnia

• Agitation

• Dry mouth

• Headache

Contraindications:

• Seizures or taking meds that lower the seizure threshold.

• Eating disorders

• Anxiety disorders

Varenicline (Chantix)

-Partial nicotinic receptor agonist

• Prevents withdrawal symptoms

• Blocks nicotine reward pathway

-Most effective medication for smoking cessation.

-Choose a fixed, flexible, or gradual quit date; quitting in a few days is not unheard of.

AE:

• Nausea

• Insomnia

• Abnormal dreams

• HA, skin rash

• Serous neuropsychiatric symptoms → (depression, SI, agitation) do NOT give to someone with a psych disorder!!