substance use disorder

a cluster of cognitive, behavioral and physiological symptoms indicating that the individual continues using the substance despite significant substance related problems

a cluster of cognitive, behavioral and physiological symptoms indicating that the individual continues using the substance despite significant substance related problems

substance use disorder

what is an important characteristic of substance use disorder

there is an underlying change in neurologic pathways that may persist beyond detoxification, esp in ppl w severe disorders

who is at higher risk for substance use disorder

ppl w depressive disorders, bipolar, anxiety disorders, PTSD, eating disorders, schizophrenia, adhd, personality disorders (esp borderline and antisocial)

mild substance use disorder will exhibit how many criteria

2-3

moderate substance use disorder will exhibit how many criteria

4-5

severe substance use disorder will exhibit how many criteria

6+

impaired control over substance use may manifest as what diagnostic criteria

substance taken in larger amounts or over a larger amount of time than intended

a persistent multiple unsuccessful efforts to dec or stop use

a great deal of time spent obtaining the substance, using the substance or recovering from it

craving is manifested by an intense desire for the frug that is more likely when in an environment where the drug previously was obtained or used

desire to cut down or regular substance use

social impairment may manifest as what diagnostic criteria

recurrent substance use results in failure to fulfill major role obligations at work/school/home

substance use continued despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

important social, occupational, or recreational activities may be given up or reduced because of substance use

risky use may manifest as what diagnostic criteria

recurrent substance use in situations in which its physically hazardous

continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem thats likely to have been caused or exacerbated by the substance

pharmacological criteria for substance abuse disorder may manifest as what diagnostic criteria

tolerance: requiring a markedly inc dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose in consumed

withdrawal: physiological change to the sudden quitting or diminished use of the substance which the body is dependent on

when does the american acedemy of pediatrics recommend screening for adolescent use of alc, tobacco and other drugs

starting at age 11

when screening an adolescent for alc/tobacco/drug use with the CRAFT screen what counts as a positive screening

2+ positive answers

what questions are in the CRAFT screening questionaire

Car (ridden in a car driven by someone not sober)

Relax (do you use drugs/alc to relax)

Alone (do you ever use alone)

Forget (do you forget things you did while using)

Friends/family (do friends/family tell you to cut down)

Trouble (have you ever gotten into trouble when using)

what screening tools can we use when screening adults for substance use disorder

AUDIT-C or CAGE for alcohol, Rapid Opioid Dependence Screen for opioids

when do you often discover substance abuse in adults

found incidentally or when investigating worsening health

what questions are included in the AUDIT-C questionnaire

how often did you have a drink in the last year?

how many drinks containing alc did you have on a typical day when you were drinking in the past year?

how often did you have 6 or more drinks in one night in the past year?

what questions are included in the CAGE questionnaire

have you ever felt you should CUT down on your drinking?

have ppl ANNOYED you by criticizing your drinking?

have you ever felt bad or GUILTY about your drinking

have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYEOPENER)

what does substance use disorder management require overall

multi-disciplinary approach that varies based on substance and individual details

what non pharmacological things are needed for substance use disorder treatment

PT WILLINGNESS, medical detox, 1:1 therapy, group therapy, family therapy, long term community resource involvement

what substances have withdrawals that can kill you

alc and benzos

how do we medically detox a pt addicted to alc or benzos

both require tapering with benzos to avoid dangerous/lethal withdrawls. often chlordiazepoxid and clonazepam are used bc theyre long acting

mental disorders directly caused by the effects of drugs or alc, like psychosis, depression or anxiety

substance induced disorder

what alc conc would likely cause unresponsiveness or extreme drowsiness, incoherent speech, memory loss, vomiting and could be lethal depending on the persons experience

300mg/dL (BAC 0.3)

what alc conc would likely be lethal

400mg/dL or more (BAC 0.4+)

what does chronic alc use do neurally

suppress GABA production (leads to tolerance)

what does alc use do to gaba and glutamate receptors

induces gaba insensitivity and glutamate receptor upregulation (alc suppresses glutamate adn glutamate systeem inc production of glutamate when alc is used chronically to maintain equilibrium)

sx of alc withdrawl (occurs less than 6hrs after not drinking or if blood alc is relatively low)

insomnia, tremulousness, mild anxiety, GI upset, anorexia, headache, diaphoresis, palpitations

sx of serious alc withdrawl (can occur 72-96hrs after last drink)

hallucinations (visual), seizures, delirium tremens (hallucinations, disorientation, tachyardia, htn, hyperthermia, agitation, diaphoresis) death

alc withdrawl tx

thiamine, folate, a LOT of benzos (lorazepam, diazepam, chlordiazepam), refractory to benzo tx (phenobarbital, propofol)

examples of stimulants

coke, amphetamines, synthetics (bath salts, ecstasy, molly, flakka, synthetic MJ)

sx of stimulant intoxication

hyperthermia, sweating, pupillary dilation (mydriasis), tachycardia, arrhythmias, elevated bp, nausea, vomiting, evidence of weight loss w chronic use, agitation, confusion, seizures, dyskinesias, dystonia, coma

symptoms of stimulant withdrawl

fatigue (catecholamine exhaustion), dysphoric mood, vivid/unpleasant dreams, hypersomnia, inc appetite, psychomotor retardation/agitation

stimulant withdrawal tx

IV fluids, nutrition, time (theyll hate it but they wont die)

what opiate is cheap and easy to make and is becoming a really big problem bc its 50x stronger than heroin and 100x stronger than morphine

fentanyl

what is the most inappropriately used opioid

heroin

using heroin subcutaneously (bc pt doesnt have IV access) may cause what

causes “skin popping” (skin necrosis regions that can get huge)

sx of opiate intoxication

pinpoint pupils (miosis), sleepiness/unresponsiveness, shallow/infrequent respirations, snoring breath sounds, bradycardia, cyanosis

opiate intoxication/OD tx

naloxone (narcan) may need to strap down the pt, be prepared for acute withdrawl and may need to dose multiple times

opiate withdrawal sx

dysphoric mood, nausea, vomiting, muscle aches, lacrimation, rhinorrhea, pupillary dilation, piloerection (goosebumps), sweating, diarrhea, yawning, fever, insomnia

short term opiate withdrawl tx

clonidine (centrally acting alpha agonist, blocks autonomic effects of opiate withdrawl)

long term opiate withdrawl tx

buprenorphine (partial mu opiate agonist, slow dissociation from opioid receptors so only dose 3x a week)

methadone (synthetic opioid that suppresses withdrawl sx

sx of cannabis hyperemesis syndrome

abdominal pain, vomiting, nausea typically relieved by hot showers (pt often say the weed helps and dont realize the weed is causing it)

cannabis hyperemesis syndrome treatment

IV hydration, droperidol (blocks dopamine), antiemetics and benzos, haldol or capsacin cream on the stomach

(still need to do full workup in case they also have other stomach issues)