Behavioral med Substance Use Disorders

use

taking a psychoactive substance for non-medical purposes with negative consequences

abuse

drug use that leads to problems

misuse

similar to abuse, but usually applies to drugs prescribed by physicians that are not used properly

intoxication

a reversible syndrome caused by a specific substance that affects memory, orientation, mood, judgement, and behavioral, social, or occupational functioning

addiction

repeated and increased use of a substance, the deprivation of which gives rise to symptoms of distress and an irresistible urge to use the agent again; leads to physical and mental deterioration

dependence

maladaptive pattern of drug use leading to clinically significant impairment to clinically significant impairment or distress

assoc w difficulty in controlling drug taking behavior, withdrawal, and tolerance

tolerance

increased amounts of the drug are needed to produce desired effects

withdrawal

series of temporary physical and psychological symptoms that occurs when continued substance use stops

hallmarks of substance use disorder (SUD)

behavioral- substance seeking activities, pathological use patterns

physical- physical effects of multiple episodes of substance abuse

psychological- continuous or intermittent craving for the substance to avoid a dysphoric state

10 classes of drugs related to SUD

alcohol

caffeine

cannabis

hallucinogens

inhalants

opioids

sedatives, hypnotics, and anxiolytics

stimulants

tobacco

other substances

patients with lower levels of _____ may be predisposed to develop SUD

self-control

SUD epidemiology

starting drug use at a younger age

higher correlation btwn SUD and other psychiatric disorders

unemployed, work from home, own boss

SUD and healthcare workers

possibly linked to increased stress, access to substances, stigma surrounding seeking help

MC prescription drug misuse (opiods and benzodiazepines)

biological factors in SUD

susceptibility to acute psychopharmacologic effects of a given drug

metabolism

cellular adaptation w/in the CNS to chronic exposure to the drug

predisposing personality characteristics

susceptibility to medical and neruopsychiatric complications of chronic use

psychologic factors of SUD

co-occurring psychopathology, medical illnesses, past/present severe stress

social factors of SUD

peer group attitudes

availability of competing alternatives

availability of drug (esp during vital developmental stages)

early use

evaluation of SUD

detailed inventory of substance type, amount, frequency, consequences, perception, readiness to change, route

thorough PMH

psychosocial factors

physical exam (mental status exam, general, vitals, hygiene, skin, eyes, nasal mucosa)

lab tests

screening for SUD

DAST-10 (doesn't include alcohol)

ASSIST (use if suspecting more than 1 substance use)

SUD DSM-5 criteria

maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 or more over 12 months:

-recurrent substance use resulting in failure to fulfill major role obligations

-recurrent substance use in situations in which it is physically hazardous

-continued use despite having persistent problems caused or exacerbated by the effects

-tolerance

-withdrawal

-great amount of time trying to acquire the substance

-important activities given up due to use

-continued despite knowledge of problem

-craving/strong desire to use

DSM-5 severity specifiers- mild

2-3 criteria

DSM-5 severity specifiers- moderate

4-5 criteria

DSM-5 severity specifiers- severe

6+ criteria

SUD nonpharmacologic treatment

education, 12-step programs, enhancement of coping strategies, relaxation training, family therapy, lifestyle changes, psychotherapy, vocational & physical rehab, recreational therapy, health and nutrition counseling, spiritual growth

MC SUD

alcohol use disorder

alcohol intoxication and withdrawal can be

fatal

alcohol use and abuse is MC in

males

alcohol abuse reduces life expectancy by

10 years

population with greatest AUD prevalence

young adult 18-29yo

native americans

native born americans

environmental factors for AUD

easy access to alcohol

legal (age permitting)

psychological factors for AUD

positive reinforcement

self-medication

personality disorders (antisocial personality disorder)

biological factors of AUD

genetic influence

rate of problems increases with # of alcoholic relatives, severity of their illness, closeness of genetic relationship

at-risk drinking in men

>14 drinks/week or 4 drinks per occasion

at-risk drinking for women

>7 drinks/week or 3 drinks per occasion

CAGE questionnaire

cut down, angry/annoyed, guilty, eye opener

2 or more suggest that the patient has a problem- needs further w/o

AUDIT questionnaire

alcohol users disorders identification test

8 or greater indicates unhealthy alcohol use

20 or greater suggests alcohol dependence

AUD clinical presentation

can be asymptomatic

cognitive impairment

motor impairment

decreased LOC

GI issues- N/V

pulmonary issues- resp depression

other- hypotension, bradycard

Blood alcohol content (BAC) legal limit

0.08% +

BAC 0.0-0.05%

relaxed/happy

difficulty w coordination, balance

decrease in ability to think clearly

BAC 0.06- 0.15%

more impairment of speech, balance, coordination

possible aggression

impaired ability to drive

BAC 0.16-0.30%

blackouts

alcohol poisoning

BAC > 0.30%

can be fatal

AUD withdrawal

delirium tremens (DTs)

general irritability

CV - tachy, HTN (earliest signs)

anxiety

diaphoresis

insomnia

GI upset

depression

dilated pupils

delirium tremens

severe withdrawal symptoms; tremors, confusion, high fever, and hallucinations

occurs 48hr + after last alcoholic drink

6-12 hrs after last alcoholic drink in AUD

minor withdrawal

12-24 hrs after last alcoholic drink in AUD

alcoholic hallucinosis

24-48 hrs after last alcoholic drink in AUD

seizures

AUD- LFTs

AST/ALT modest elevations

AST:ALT ratio of 2:1 suggests alcohol-induced liver disease

AUD CBC

anemia, pancytopenia, macrocytosis

AUD GGT

elevated levels

normal ranges: 8-40 (F), 9-50 (M)

AUD uric acid and triglyceride levels

elevated

AUD treatment

ER/ICU - IV fluids, monitoring for aspiration

inpatient hospital

AA

CBT

counseling/therapy

Naltrexone (first line)

Disulfram

treatment for AUD once abstinence is achieved

Acamprosate

helps w symptoms of dysphoria

naltrexone

opioid antagonist; blocks feelings of entoxication

disulfram

produces acute sensitivity to alcohol

treatment for alcohol withdrawal

benzodiazepines- diazepam (valium), chlordiazepoxide (librium)

helps control withdrawal symptoms

alcohol induced persisting amnestic disorder

acute neruopsychiatric emergency

disturbance in short term memory caused by prolonged heavy use of alcohol

Wernicke's encephalopathy and Korsakoff's syndrome

Wernicke's encephalopathy

acute, due to thiamine deficiency

reversible w treatment

triad of eye movement abnormalities (nystagmus), ataxia, mental confusion

Wernicke's encephalopathy treatment

give thiamine FIRST then glucose

Korsakoff's syndrome

progression of Wernicke's encephalopathy

few improve/irreversible

impaired mental syndrome, anterograde amnesia, confabulation

Korsakoff's syndrome treatment

long term thiamine and nutritional support

good prognostic indicators in AUD

female, older, married

tobacco use disorder

strong craving after eating or experiencing stress; multiple forms of tobacco ingestion

greatest prevalence of TUD

schizophrenia

depression

children have increased risk of TUD if

parents smoke

tobacco withdrawal occurs with

abrupt discontinuation

tobacco withdrawal symptoms

irritability, anxiety, restlessness, poor concentration, sleep disturbances, hunger, wight gain, depressed mood, craving that can last years

long term tobacco use decreases

cerebral blood flow

TUD treatment

buproprion SR

varenicline (Chantix) *drug of choice

nicotine replacement therapies

clonidine (not FDA approved)

nortriptyline (off label second-line option, not FDA approved)

cannabis use disorder

impairment can occur after 1-2 joints and persists 4-8 hours

withdrawal symptoms may not be well characterized due to slow elimination

MC used illicit drug

cannabis

F>M

cannabis intoxication

euphoria, drowsiness, sedation, sensation of slowed time, auditory/visual distortions, dissociation

impaired judgement, motor coordination, attention, memory

conjunctival injection, tachycardia, increased appetite

anxiety, acute panic reactions, paranoia, illusions, agitation

cannabis withdrawal

insomnia, irritability, dysphoria, aggressiveness, depression/craving, strange vivid dreams, tremor/shakiness, muscle twitches, HA< mild fever, chills, anorexia, nausea, weight loss

CUD treatment

none approved or recommended

rehab/therapy

lifestyle change is vital

opioid use disorder

heroin, morphine, fentanyl, codeine, oxycodone, hydrocodone, opium

significant cause of morbidity and mortality due to accidental overdose

medical professions at risk

opioid intoxication

activation or rush, euphoria or dysphoria

feelings of warmth, facial flushing, itching

impaired judgement, attention, or memory

analgesia, constipation, pupillary constriction, drowsiness

respiratory depression, areflexia, hypotension, tachycardia, apnea, cyanosis, coma

opioid withdrawal

depressed mood and anxiety, dysphoria, craving, piloerection, lacrimation or rhinorrhea

hyperalgia, joint and muscle aches

N/V/D/cramps

pupillary dilation and photophobia

insomnia, autonomic hyperactivity, yawning

OUD treatment

naloxone (reversal)

methadone (kills craving, also addictive)

buprenorphine (prevents cravings w/o feelings of being high)

psychodynamic and cognitive therapy

opioids are commonly used with

alcohol

contributing factor in may opioid deaths

co-use of opioids and alcohol treatment

integrated CBT therapy

mindfullness-based treatment

+/- methadone

naltrexone

hallucinogen use disorder

PCP, MDMA, ketamine, anticholinergics

heavy use leads to flashbacks, mood lability, personality disturbances, and possible dementia

withdrawal from hallucinogens may lead to

random violence

hallucinogen intoxication

marked anxiety or depression

perceptual changes

thought disorders

impaired judgement

autonomic arousal

motor impairement

HUD treatment

benzodiazepines

physical restraints

antipsychotics for hallucinogen-induced psychosis

sedative, hypnotic, anxiolytic use disorder

sedative: barbituates

hypnotic: zolpidem, zaleplon, eszopiclone

anxiolytic: benzodiazepines

benzodiazepine acute intoxication

respiratory depression

benzodiazepine withdrawal

same as alcohol- anxiety, insomnia, depression

benzodiazepine dependence treatment

gradual withdrawal, maintenance treatment, psychotherapies

benzodiazepine overdose treatment

flumazenil

stimulant use disorder

cocaine (inhalation, smoking, IV) and amphetamines

stimulant intoxication

stimulation, psychomotor agitation, energy, anorexia, autonomic arousal, CP, cardiac arrhythmias, respiratory depression, confusion, seizures

stimulant withdrawal

depression

psychomotor retardation

fatigue

increased appetite

craving

stimulant use disorder treatment

CBT

inhalant use disorder

gasoline, acetone, toluene, paints, paint thinners, glues, refrigerants, nitrous oxide, amyl nitrite

pre-teens, teenagers

used for several days

IUD clinical presentation

chemical odors, stains on hands/fingers/clothes, behavioral changes, significant decrease in weight/appetite, sudden social changes/rapid decline in school performance, change hygiene, slurred speech, runny nose/epistaxis, fatigue, irritation, confusion/poor concentration, depression, irritability, paranoia

IUD withdrawal

N/V, diaphoresis, tachycardia, tremors, sleep disturbance, psychosis, seizures

IUD treatment

elimination of toxin

treat acute symptoms- stabilize ABC's

CBT, motivational interventions, family counseling, activity and engagement programs, support groups

other addictive disorders

gambling, caffeine, anabolic-androgenic steroid abuse, sex, stealing