Substance related disorders

what is the criteria for substance use d/o

pt is using a substance more than what is intended and for longer.

there is intention and failed attempts to dec their use.

extra time is used to get the substance or recover after taking them.

strong craving

you can’t fulfil your typical responsibilities

continued use after social impairment.

you give up other activities

using it in a high risk setting like driving a car

using it w/o considering the harmful effects

developing a tolerance to it

withdrawal after the substance is d/c

how many of the criteria do you need to hit in order to have a substance use d/o

2-3 mild, 4-5 mod, >6 severe

priority of drug seeking over other behaviors while trying to maintain dysfunctional drug use

dependence syndrome

how does someone develop a substance use disorder

long term exposure to substances causing mental and physical dependence.

4 c’s of addiction

Compulsive use, loss of Control, Craving, Continued use even w negative consequences

what is the most prevalent substance misused in the US

alcohol

presentation varies widely. pt is intoxicated, withdrawing, or with physical/psych conseq of chronic alc consumption. can have hx of another drug or nic addiction. can can primary psych illness, abuse/trauma, and +FHx of this d/o

substance use d/o

Cardiovascular signs of alc use d/o

HTN, cardiomyopathy, inc Tg

GI sx of alc use d/o

cirrhosis, vomit, pancreatitis, duodenal ulcers

endocrine sx of alc use d/o

feminine appearing men

hematologic sx of alc use d/o

anemia, B1 def, thrombocytopenia, macrocytosis

oncology sx of alc use d/o

inc ca risk, liver, stomach, esophageal, pancreatic ca

neuro sx of alc use d/o

cognitive impairment, paresthesias, ataxia

MSK sx of alc use d/o

presence of an injury, inc fall risk, car accidents, fights

sexual sx of alc use d/o

ED in men

AUDIT screening for alc use d/o is

identifying at risk drinking and detect harmful drinking behavior. 0-4 rating for each question. 8+ score = serious alc use. AUDIT-C is used more. Limit is that it’s not good at detecting AUD in older pops

CAGE questionairre

have you ever felt the need to cut down on drinking? have people around you been annoyed by you drinking? have you ever felt bad or guilty about your drinking? have you ever had a drink first thing in AM to steady your nerves or rid a hangover (eye opener)? >/=2= AUD. limitation is that it can’t distinguish b/w past and current d/o

what labs are helpful to determine alc use d/o

BAL >35 in an alert pt shows a high tolerance. GGT if >35 = heavy drinking (false pos in pregnancy, smokers, and obesity). alanine and aspartate aminotransferase ratio, carb deficient transferrin test, MCV >100 = heavy drinker, also inc in B12/folate acid def

what does a brain CT show in a person with AUD

volume loss, shrinkage of brain tissue. shrinkage of frontal lobe, ventricular enlargement, widening of cortical sulci. shrinkage thalamus, inferior colliculus, mallillary bodies = wernicke/korsakoff dz. 

a pt with alc intox can have similar sx to 

lithium tox, medical conditions like hypoglycemia, hypothyroidism, CVA, head injuries, hepatic encephalopathy, DKA, metabolic derangements.

a pt with alc withdrawal can have similar sx to

stimulant intox, med conditions like thyroid storm, essential tremor

reduction or stopping alc in pt who depends on it leads to

imbalance of excitatory and inhibitory neurotransmission = excessive NMDA pathway activity and dec GABA activity. 

a score of >15 on the CIWA-Ar scale indicates what for a pt with alc withdrawal

severe withdrawal, inpt, close monitoring

a score of 8-15 on the CIWA-Ar scale indicates what for a pt with alc withdrawal

moderate withdrawal. outpt, monitoring

a score of <8 on the CIWA-Ar scale indicates what for a pt with alc withdrawal

mild withdrawal. outpt, monitoring

pt has hand tremor, HA, anorexia, n/v, sweating, insomnia, tachy, HTN, psychomotor agitation, craving, anxiety. also seizures, hallucinations, delirium. sx began 2-6 hrs after reducing consumption of alc persisting for 2 weeks. this dz is

alc withdrawal

pt presents with/out hand tremors and flu like sx. they report seeing tactile and visual and auditory hallucinations, like it looks like insects are everywhere. they know it isn’t actually real. this is a

withdrawl hallucination

tonic clonic seizures can occur between what time frame of alc withdrawal

6-48 hrs later. half assoc with underlying epilepsy, brain lesions, or substance use. some develop delirium tremens

acute and fluctuating disturbances in consciousness, confusion, agitation, inattention, impaired cognitive function. hallucinations, life threatening fluid, metabolic, an electrolyte imbalances. autonomic instability. this is

delirium tremens

gold standard tx for alc withdrawl and delirium tremens

long acting benzos (inhibits GABA, relieves sx and prevents delirium tremens and seizures. chlordiazepoxide and diazepam).

what AUD tx causes respiratory depression and isn’t really used

barbiturates

what AUD tx is as effective as benzos for mild-moderate withdrawal

anticonvulsants like carbamazepine and valproic acid

what AUD tx is used to dec psych sx like agitation and hallucinations, but does NOT tx the progression or reversal of delirium tremens or withdrawal seizures

neuroleptics

what AUD tx is used to replenish nutrient stores and is protective against Wernicke-Korsakoff (encephalopathy and dementia)

thiamine

what AUD tx is helpful in highly motivated pts committed to abstinence bc it’s an aversive agent. will cause face flushing, dizziness, blurred vision, n/v, palpitations, weakness, HoTN, tachy. 

disulfiram

AE for using disulfiram to tx AUD

seizures, respiratory depression, MI, and death. pts o this drug feel bad when they drink alc, so if they stop using the meds they’ll feel fine.

what AUD tx blocks effects of alc related release of endogenous opioids triggering the good effects of alc?

naltrexone

adverse effects of using naltrexone for AUD tx

GI/sedative, precipitates opioid withdrawal and blocks analgesic effects of opioids

this AUD tx is an NMDA glutamate receptor antagonist and is a good option for pt with a compromised liver. 

acamprosate

this AUD tx is an anticonvulsant with efficacy in dec alc consumption.

topiramate

what are the adverse effects of topiramate tx for AUD

anorexia, cog impairment, paresthesias, taste perversion

what are psychotherapeutic interventions that can be used for AUD

CBT identifies triggers and refusal skills. AA meetings provide a social support network

what is the typical prognosis of pts with AUD

they usually age out of it. pts who are heavy drinkers can have a motor vehicle accident, cirrhosis, ca, homicide/suicide, hemorrhagic stroke. organ damage from alc is irreversible

principal psychoactive constituent of cannabis is

dleta-9-tertrahydrocannabinol (THC)

euphoria, relaxed, inc appetite, cog impairment, impaired motor coordination after taking cannabis is what type of sx

acute effects

pt took weed, they have dry mouth, conjunctival injection, tachy, orthostatic hypotension. these types of sx are

physiological effects

pt stopped taking weed and now they have sx of anger, aggression, appetite change, weight loss, irritability, anxiety, restlessness, altered sleep, strange dreams, cravings, physical discomfort.

withdrawal sx

chronic use of cannabis leads to what sx

amotivational syndrome. cannabinoids produce a full range of schizophrenia like pos, neg, and cognitive sx

THC can be detected in what screenings

plasma, saliva, nails, and hair. synthetic cannabis is undetectable in utox

MRI studies show what in chronic cannabis use

glutamatergic and GABAergic abnormalities

how to tx cannabis use d/o

rarely anxiolytics and/or antipsychotics are used to tx anxiety or psych sx.

what are the type sof hallucination mechanisms

serotonergic, NMDA antagonist, other.

pt explains that they took something and they have heightened/diminished sensory inputs (colors, textures, sounds, tastes, touch), sensory inputs immerse person so they disregard all else, illusions (distortions perceived as real objects), frank hallucinations, synesthesia, distorted time perception, depersonalization, derealization. what did they take

hallucinogen

what hallucinogens can be found in utox

ketamine and PCP

what is seen on neuroimaging of a pt who chronically uses ecstasy

reduced serotonin transporter in midbrain, thalamus, and cortical region. 

MRI scans of pts who depend on ketamine show

dec frontal cortex gray matter volume and white matter abnl, cortical atrophy, dec white matter integrity

how to tx adverse emotional reactions to a hallucinogen

librium and valium

3 sx clusters for opioid related risoders

loss of control, prominent behavioral rep, craving

chronic hallucinogen use leads to

mood lability, cog deterioration, personality alterations

when determining opioid related d/o in a pt we must concentrate on the following 2sxs clusters

loss o control, prominence to behavioral rep, craving

how can you tell that someone is in opioid intox

hx of recent ingestion, euphoria, pupillary constriction, slowed respiratory rate, drowsiness, slurred speech, inattention.

how can you tell a pt is in opioid withdrawal

dysphoria, n/v/d, muscle aches, lacrimation/rhinorrhea, pupils dilated, piloerection (goosebumps), sweating, yawn, fever, insomnia. happens in minutes or day safter stopping or being given a reversal agent like naltrexone, buprenorphine.

what psych d/o is most commonly assoc with OUD

PTSD

what is the opioid risk tool (ORT)

5 question test to see what pt can get drug related d/o. 

what is the current opioid misuse measure (COMM)

17 item self assessment tool to help clinicians identify if a pt has bad behaviors assoc with misuse of opioids

what is the drug abuse screening test (DAST)

28 tru or false ques that identify a current drug disorder

what is a clinical opioid withdrawlal Scale (COWS)

11 item questions used to assess presence of and extent of withdrawal

what labs show a pt has OUD

pos utox, leukocytosis during detox, test for HIV, syphilis, tuberculin skin test, ECG if you want methadone maintenance therapy, CXR rule out TB

what does neuroimaging show in a pt with OUD

neurovascular d/o, leukoencephalopathy, atrophy. ventricular enlargement and frontal lobe loss, autopsy shows hi cerebral edema

what is the mainstay therapy tx for OUD

CBT. same results as giving buprenorphine

first line of tx of acute opioid overdose

naloxone. might need repeat dose bc half life is short.

SE of using naloxone for opioid OD

flash pulmonary edema

how to tx opioid withdrawal

clonidine

how to tx GI sxs in opioid withdrawal

dicyclomine

how to tx insomnia with opioid withdrawal

antihistamines

to tx muscle aches in a tp with opioid withdrawal

NSAIDs

how to tx n/v in a pt in opioid withdrawal

promethazine or metoclopramide

how to tx muscle spasms in a pt with opioid withdrawal

methocarbamol

how to tx diarrhea in a pt with opioid withdrawal

loperamide

what are the 3 approaches to opioid relapse prevention

agonist, partial agonist, antagonist

what is the agonist you can give for opioid relapse prevention

methadone, a long acting med used long term. make sure to follow EKGs bc of QTc prolognation

what is the partial agonist you can give for opioid relapse prevention

buprenorphine, used w nalxone

what is the antagonist you can give for opioid relapse prevention

naltrexone, reserved for very motivated pts. removes the rewarding effects of using opioids

psychotherapeutic interventions and medically assisted detox programs have a worse outcome of successful opioid detox in comparison to 

maintenance or detox coupled with CBT and individual counseling

what are positive prognostic indicators for opioid remission

shorter opioid use hx, only PO opioids, not using heroin, fewer prior tx attempts, inc social stability.

what is the most likely drug to be assoc with ED visits

a stimulant like cocaine, meth, or MDMA

enhanced energy, dec fatigue, euphoria, hyperalert, grandiosity, alert, sociability after taking a drug. 

stimulant intox

adverse effects of stimulant consumption

dysphoria, anxiety, restlessness, stereotypical behavior, psychomotor agitation, impaired judgement.

agitation is a problem with what type of stimulant

meth

stimulant induced psychosis is sene in what type of stimulant users

high dose chronic users

what consists of stimulant induced psychosis

paranoia, stereotyped compulsive behavior.

LOC, disorientation, perceptual disturbances like auditory and visual hallucinations

stimulant delirium, indicative of OD

what stimulant drug shows psychotic sxs more

meth

what is seen on neuroimaging in a pt who takes stimualnts

poor white matter integrity, dec gray matter in frontal region

how are ADHD and stimulants related

we typically give pts stimulants to tx this condition.

how to tx acute intox of stimulants

put them in quiet safe environment,, give benzos for intense agitation, antipsychs for extreme paranoia or psychosis (dec seizure threshold and inc hypothermia). 

what should you avoid in a tp with acute stimulant intox

BB bc of risk of coronary spasms. vasoconstrictors leading to MIs

how to tx stimulant withdrawal

can give benzos for intense agitation or bad sleep, if they’re depressed give antidepressant or psychotherapy.

how does contingency management help pts with stimulant addiction

dec substance behaviors thru alternate enforcers. give tangible reinforcers to maintain goals. 12 step program