BH E2- Substance Use Disorders Pt. 2

What products can methanol be found in?

Windshield washer fluid, de-icing solution, paint stripper, carburetor cleaner, model airplane fuel, solvents, solid fuel for stoves

In what kind of poisoning might symptoms be delayed?

Methanol or ethylene poisoning

What can 30 mL of methanol ingestion lead to?

Permanent blindness (optic neuritis)

How is methanol metabolized by alcohol dehydrogenase?

formaldehyde → formic acid → toxicity & metabolic acidosis

The following ssx are seen with what kind of intoxication?

• tachypnea, dyspnea, tachycardia

• blurred vision, hazy snow like patterns

• hyperemia of optic disc, pupillary dysfunction

• HA, dizziness, abd pain, N, V

• variable degrees of CNS depression

• inc osmolar gap

Methanol intoxication

What is the treatment for methanol intoxication?

Hospitalize, secure airway

Fomepizole (alt ETOH), Folic acid, Sodium bicarbonate (if pH < 7.3)

Hemodialysis if indicated

contact poison control

What should NOT be used in the treatment of methanol intoxication due to it being ineffective from rapid absorption?

Gastric lavage & activated charcoal

What is the dose for fomepizole in the treatment of methanol intoxication (blocks alcohol dehydrogenase)?

15 mg/kg IV loading dose then 10 mg/kg Q12h x 4 doses

What is the dose for folic acid in methanol intoxication treatment?

50 mg IV Q6h

What can be used as an alternate to fomepizole in the treatment of methanol (or ethylene glycol) intoxication?

ETOH therapy - metabolized preferentially to methanol

*SEs- CNS depression, hypoglycemia, GI irritation

What is the dose of ETOH therapy used to treat methanol intoxication?

10 ml/kg of 10% soln then 1 ml/kg of 10% soln infused per hour

Titrate to serum concentration 100 mg/dL (0.1%)

Why is fomepizole better than ETOH in methanol intoxication treatment?

No monitoring of levels & lacks SEs

When is hemodialysis indicated in the treatment of methanol or ethylene glycol intoxication?

Methanol blood concentration > 50 mg/dL

Severe acidosis (pH < 7.25 w/ AG > 30)

End organ damage → visual changes, renal failure

What products can ethylene glycol be found in?

Antifreeze & de-icer solutions

*sweet tasting & attractive colors

How is ethylene glycol metabolized by alcohol dehydrogenase?

glycolate → oxalate (precipitates w/ calcium to form oxalate crystals)

When do sx occur with ethylene glycol ingestion?

30 minutes - several hours

The following sx are seen in what phase of ethylene glycol intoxication?

• 30 minutes-12 hrs post ingestion

• CNS depression

• ± abd pain, N, V

• metabolic acidosis & hypocalcemia

Phase 1

The following ssx are seen in what phase of ethylene glycol intoxication?

• tachycardia

• HTN

• tachypnea

• HF

• pulm edema

Phase 2

The following ssx are seen in what phase of ethylene glycol intoxication?

• renal tubule necrosis

• flank pain

• hematuria

• renal failure

Phase 3

What other ssx may be present with ethylene glycol intoxication?

Osmolar gap, severe acidosis, calcium oxalate crystals in urine, fluorescent urine under woods lamp (from additives in antifreeze)

*No visual sx, ocular fundi are normal

What is the treatment for ethylene glycol intoxication?

Hospitalize, fomepizole or ethanol, bicarb if acidosis, hemodialysis

Mag sulfate, thiamine, pyridoxine

contact poison control

What is the dose of magnesium sulfate for ethylene glycol intoxication treatment?

2gm IV

What is the dose for thiamine for ethylene glycol intoxication treatment?

100 mg IV q6h x 2 days

What is the dose for pyridoxine for ethylene glycol intoxication treatment?

100 mg IV q6h x 2 days

What products can isopropanol be found in?

Rubbing alcohol

What is isopropanol metabolized by alcohol dehydrogenase into?

acetone

The following ssx are present in what condition?

• elevated osmolar gap, acidosis rare

• fruity odor of acetone on breath (w/o acidosis is characteristic)

• CNS & cardiac depression

• ketonuria, ketonemia

• abd pain, N, V

• *not as toxic as methanol or ethylene glycol

Isopropanol intoxication

What is 2x more potent than ethanol for CNS depression & lasts 2-4x longer?

Isopropanol

What labs should you get in isopropanol intoxication?

Serum isopropanol & acetone levels, glucose (hypoglycemia), CMP, urine ketones

What is the treatment for isopropanol intoxication?

Supportive, ETOH

Hemodialysis if levels > 400 & significant CNS depression

Hospitalize if stupor, coma, hypotension

What should be avoided in the treatment of isopropanol intoxication?

Lavage, charcoal, fomepizole

The following criteria is for what condition?

• problematic pattern of (substance) use leading to significant impairment/distress w/ ≥ 2 of the following w/in 12 mo period:

  • take larger doses or over longer period of time than intended

  • persistent desire/unsuccessful efforts to cut down

  • alot of time spent to obtain, use, or recover from substance

  • craving or strong urge to use substance

  • recurrent use resulting in failure to fulfill obligations

  • continued use despite problems

  • activities given up or reduced bc of substance use

  • recurrent use in harmful situations (like driving)

  • use continued despite knowing negative consequences

  • tolerance sx

  • withdrawal sx

• mild: 2-3 sx

• mod: 4-5 sx

• severe: ≥ 6 sx

Any substance abuse disorder

What drug?

• opioid pain reliever → CNS depressant that creates state of euphoria or ecstasy

  • similar to endorphin, v lipophilic & crosses BBB

• MC abused opioid associated w/ dependence

• #1 killer

• 2-4x more potent than its parent form, morphine

Heroin

How can heroin be used?

Smoked, injected SQ/IM/IV, intranasal (snorted/sniffed), or PO

*effects felt almost immediately, peak effect w/in 10-15 minutes for all forms

What are street names for heroin?

Horse, smack, brown, dope, mud, speedball, chasing the dragon (inhaling vapors after powder is heated on aluminum foil), & china white (laced with/ fentanyl)

What is speedball?

Injecting heroin w/ cocaine

What receptors regulate & mediate analgesia, respiratory depression, constipation, and sedation?

Opioid receptors

What physical effects are seen with heroin?

Euphoria, skin flushing, heavy extremities, confusion, constipation, “the nod” (wakefulness/drowsiness atlernation) progresses to death

What are the harmful effects of heroin?

Severe resp suppression progresses to resp arrest to death

What are the long term effects of heroin?

Malnutrition, skin abscesses, spontaneous abortions, birth defects, inc infx

What is the following condition?

• use of heroin as anti anxiety agent to mask feelings of low self esteem, hopelessness, and aggression

• pt has:

  • underlying depression often w/ anxiety

  • impulsiveness expressed by passive aggressiveness

  • fear of failure

  • limited coping strategies & low frustration tolerance w/ need for immediate gratification

Heroin behavior syndrome

What are examples of synthetic opioids?

Oxycontin (oxycodone), dilaudid (hydromorphone), meperidine (demerol), methadone (dolophine), pentazocine (talwin)

The following adverse effects are seen with what drug?

• dizzy, lightheaded, weakness

• loss of coordination, ataxia

• confusion, somnolence, insomnia

• euphoria

• dry mouth

• can cause resp depression, coma & death

Opioids

The following criteria is for what condition?

• recent use of opioid

• significant problematic changes that developed shortly after use

  • initial euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgement

  • pupillary constriction (miosis) and ≥1 of the following

    • drowsiness or coma

    • slurred speech

    • impairment of attention or memory

Opioid intoxication

What are the general signs of opioid intoxication?

Miosis (normal 2-4 mm), psychomotor retardation, drowsiness, euphoria followed by sedation (“the nods”), slurred speech, conjunctival injection, resp depression, impaired memory and attention

What condition?

• cessation/reduction in heavy or prolonged opioid use OR

• administration of opioid antagonist after period of opioid use

• ≥ 3 of the following w/in few mins to several days

  • dysphoric mood

  • N or V

  • muscle aches

  • lacrimation or rhinorrhea

  • mydriasis or sweating

  • diarrhea

  • yawning

  • fever

  • insomnia

Opioid withdrawal

What physical effects are seen with opioid withdrawal?

Insomnia, restlessness, anxiety, yawning, mydriasis, hyperreflexia & myoclonic jerking (“kicking the habit”), N/V, abd cramping

What are long acting partial opioid receptor agonists that were approved by the FDA to treat heroin and opioid addiction?

Buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone)

What drug is a full opioid receptor agonist & can only be prescribed for OUD by specific, qualified providers in federally approved opioid treatment centers?

Methadone (Dolophine)

What is the treatment for opioid overdose?

Ensure adequate airway, Naloxone (Narcan) → prompt signs of improvement (inc RR)

What usually causes death in an opioid overdose?

Respiratory arrest

What causes most opioid overdoses?

Fentanyl

*(BZOs also commonly involved)

What is the treatment for opioid use disorder (OUD)?

Support groups, abstinence

Suboxone, naltrexone, or methadone

What drug is an opioid antagonist given as a tablet or vivitrol injection to treat OUD, but requires the monitoring of LFTs & MUST be abstinent before starting (precipitates acute withdrawal)?

Naltrexone

What drug is a partial opioid receptor antagonist given in OUD as a sc injection to prevent misuse, & should be avoided in pregnancy?

Suboxone (buprenorphine w/ naloxone)

How should opioids be prescribed?

Start w/ lowest effective dose for short durations (≤3 days) for acute pain

Reassess when considering increasing ≥50 MME/day & avoid increasing to ≥90 MME/day (unless carefully justified)

What other precautions should be taken prescribing opioids?

Review PDMP/E-FORCSE data, use urine drug tests, avoid concurrent opioid & benzo use, & offer tx for OUD

How often is urine drug testing recommended for patients on controlled substances?

Every 12 mos (more often for MAT)

What are the types of urine drug testing?

Screening (dipstick) & confirmatory (gas chromatography)

*UDS only screens for MC metabolites

Do drug levels on confirmatory urine drug testing (gas chromatography) correlate to the amount of medication used?

No

What drugs are used in anxiolytic related disorders?

Benos- diazepam (valium), alprazolam (xanax) & other sedatives, hypnotics and anxiolytics

The following criteria is for what condition?

• recent use of sedatives, hypnotics, or anxiolytics

• significant maladaptive changes that developed shortly after use

  • inappropriate sexual or aggressive behavior, mood lability, impaired jdugement

• ≥ 1 of the following

  • slurred speech

  • incoordination

  • unsteady gait

  • nystagmus

  • impairment of cognition (attention/memory)

  • stupor or coma

Anxiolytic intoxication

The following criteria is for what condition?

• cessation/reduction of sedatives, hypnotics or anxiolytic use thats been heavy or prolonged

• ≥2 of the following w/in several hours-days

  • autonomic hyperactivity - sweating or HR > 100

  • hand tremor

  • insomnia

  • N/V

  • transient hallucinations

  • psychomotor agitation

  • anxiety

  • grand mal seizures

Anxiolytic withdrawal

How do withdrawals from benzos present?

Onset w/in 2-3 days, possible seizures w/ protracted use, mild sx for low doses or short duration

Anxiety, dysphoria, intolerance of bright lights/noise, N, sweating & muscle twitches

What is the treatment for benzo withdrawal?

Benzodiazepines on a taper

What is a specific benzodiazepine antagonist that can be given in a benzo OD?

Flumazenil (Romazicon)

The following criteria is for what condition?

• recent consumption of caffeine (excess of 250mg = 3 cups/ 7 sodas)

• ≥5 of the following

  • restless, nervousness, excitement, insomnia, flushed face, diuresis, GI disturbances, muscle twitching, rambling thought or speech, psychomotor agitation, inexhaustibility, tachycardia or arrhythmias (afib)

Caffeine intoxication

How much caffeine is in 1 cup of coffee?

95 mg

How much caffeine is in 1 cup of soda?

39 mg

The following criteria is for what condition?

• prolonged daily use of caffeine

• abrupt cessation/reduction of caffeine use causes ≥3 of the following w/in 24 hrs

  • HA

  • marked fatigue or drowsiness

  • dysphoric mood, depressed mood

  • difficulty concentrating

  • flu like sx (N, V, muscle pain/stiffness)

• significant distress or impairment in functioning

Caffeine withdrawal

What drugs are used in hallucinogen related disorders?

PCP, MDMA (ecstasy & Molly), synthetics (spice/K2 or flakka/bath salts)

What is PCP mixed with cannabis?

Love boat or killer weed

What is PCP mixed with cocaine/crack?

space basing

How can PCP be used?

Smoked, snorted, swallowed

The following criteria is for what condition?

• recent use of PCP

• significant problems shortly after use

  • Belligerence, assaultiveness, impulsiveness, unpredictability, psychomotor agitation, impaired judgement

• w/in 1 hour, ≥ 2 of the following

  • nystagmus, HTN, tachy, numbness or diminished response to pain, ataxia, dysarthria, muscle rigidity, seizures, coma, hyperacusis

PCP intoxication

What physical/psychologic effects does PCP have?

Inc BP, tachycardia, tachypnea, hyperthermia

delusions, paranoia, hallucinations, stuttering, severe anxiety, depression, SI, aggression, hostile behavior

The following criteria is for what condition?

• recent use of hallucinogen (MDMA, Spice/K2, Flakka, bath salts)

• significant problematic changes

  • marked anxiety/depression, ideas of reference, fear of losing mind, paranoid ideation, impaired judgement

• perceptual changes occurring in state of full awakeness & alertness

  • depersonalizations, derealization, illusions, hallucinations

• ≥ 2 of the following

  • mydriasis, tachycardia, sweating, palpitations, blurred vision, tremors, incoordination

Other hallucinogen intoxication

What population MC uses MDMA (Ecstasy & Molly)?

Adolescents & young adults; > 18 y/o

What drug?

• hallucinogen

• methods: sniffed/snorted, swallowed, smoked, injected

• physical effects: inc energy & pleasure, enhanced tactile experiences

• psych effects: distortion in time & perception

• harmful: N, hyperthermia, muscle cramps, involuntary teeth clenching, blurred vision, chills, sweating, liver failure, renal failure, HF, death

MDMA

What usually causes death w/ MDMA OD?

hyperthermia & dehydration

What population MC uses synthetic hallucinogens- spice/K2, flakka, or bath salts?

high schoolers; 8th-10th grade

What drug?

• hallucinogen

• methods: snorted, swallowed, smoked

• physical: inc mood, relaxation, altered perception

• psych: extreme anxiety & confusion

• harmful: rapid HR, vomiting, violence, SI

Synthetics - Spice/K2

What drug?

• hallucinogen

• method: snorted, swallowed, smoked

• physical: hallucinations & inc sociability

• psych: paranoia, delusions, panic attacks, agitation, violence

• harmful: depression, anxiety, tremors

Synthetics - Flakka or Bath salts

The following criteria is for what condition?

• following the cessation of hallucinogen use (days-yrs), the re-experiencing of ≥1 perceptual sx experienced while intoxicated

  • geometric hallucinations, false perceptions of movement in peripheral visual fields, flashes of color, intensified colors, trails of images of moving objects, positive after images, halos around objects, macropsia, micropsia

• *HPI- ask if they have ever used a hallucinogen

Hallucinogen persisting perception disorder (HPPD)

What drugs are used in inhalant use disorder?

Hydrocarbon-based inhalants

The following criteria is for what condition?

• recent intended or unintended short term, high dose exposure to inhalants

  • gasoline, toluene (paint thinner), spray paint propellant, AC freon “huffing”

• significant problematic changes

  • belligerence, assaultiveness, apathy, impaired judgement

• ≥2 of the following

  • dizzy, nystagmus, incoordination, slurred speech, unsteady gait, lethargy, depressed reflexes, psychomotor retardation, tremor, weakness, blurry vision or diplopia, stupor or coma, euphoria

Inhalant intoxication

The following criteria is for what condition?'

• daily use of tobacco for atleast several weeks

• abrupt cessation/reduction of tobacco use results in ≥ 4 of the following ways/in 24 hrs

  • irritability or frustration or anger,

  • difficulty concentrating,

  • inc appetite,

  • restlessness,

  • depressed mood,

  • insomnia,

  • productive cough

• causes clinically significant distress & not attributable to other condition

Tobacco withdrawal

The standard of care is to obtain a chest CT to screen for lung cancer in what patients?

55-80 y/o, 30 pack year history, currently smoking or quit w/in the last 15 yrs

What is the treatment for tobacco use disorder?

21 mg/day patch

Chantix- mixed nicotinic ag/antag

Wellbutrin SR- nicotinic antag

What is the dose for patches used to treat tobacco use disorder?

21 mg/day patch (equal to 1 pack or 20 cigs)

The following criteria is for what condition?

• problematic pattern of gambling →significant impairment or distress

• ≥ 4 of the following w/in 12 mo period

  • needs to gamble increasing amts of money to achieve desired excitement

  • restless or irritable when attempting to cut down/stop

  • repeated unsuccessful efforts to control/stop

  • preoccupied w/ gambling (thinking of past or future experiences, handicapping, & how to fund it)

  • gambles the. feeling distressed

  • after losing money, returns another day to get even (chasing one’s losses)

  • lies to conceal extent of involvement

  • has jeopardized/lost relationships, jobs, or opportunities bc of gambling

  • relies on others to provide money to relieve desperate financial situations caused by gambling

• mild: 4-5 sx; mod: 6-7 sx; severe: 8-9 sx

Gambling disorder