Substance Use: PCMII

Which Criterion are "impaired control" groupings

1, 2, 3, 4

Which Criterion are "pharmacological" groupings?

10, 11

repeated use w/ or w/out physical dependence. physical dependence indicates and altered physiologic state from repeated substance use

dependence

reversible syndrome by a specific substance that affects 1 or > memory, orientation, mood, judgment, and behavioral, social, occupational function

intoxication

substance specific syndrome that occurs after stopping or reducing the amount over a prolonged period of time

withdrawal

physiologic changes occurring w drug use. results in w/drawal sx

physical dependence

craving or desire for substance independent of the physiologic w/drawal sx

psychologic dependence

Psychiatric comorbidities are highest among which pts?

bipolar d/o, schizophrenia, antisocial personality d/o. Have more distress and fewer coping skills

what happens when a drug is withdrawn?

the compensatory response of the organism is unopposed and effects are the opposite of the sx caused by the drugs

Absolute blood concentrations can show high concentration of a substance. But if there is absence of clinical signs, what should you be thinking?

think about tolerance

what does withdrawal of alcohol look like?

tremors, shakes, jitters in 6-8 hrs. psychomotor and perception sx in 8-12 hrs, seizure, delirium tremens in 72 hrs or after 1 week

Tx for alcohol withdrawal

-Benzos (not long term) like Diazepam (Valium), Chlordiazepoxide (Librium), Thiamine, Folic Acid, multivitamin

-Disulfiram (Antabuse) will cause nausea when alc is consumed

Tx for withdrawal from other CNS depressants

phenobarbital

tx for acute agitation in stimulant withdrawal

anxiolytics or neuroleptics

Tx to reverse the effect of any opioid

Naloxone

PCP and Hallucinogen: acute psychosis tx

Neuroleptics such as haldol

Nicotine and tobacco tx

nicotine transdermal patches, nasal spray, gum, inhaler, antidepressants, clonidine

ETOH, Benzo, Barbiturates, Sedatives, Hypnotics, Anxiolytics

Depressants

Amphetamine, Ephedrine, Crank, Crack (Cocaine), Ecstasy, Methamphetamine, Cocaine, Caffeine

Stimulants

LSD lysergic acid derivatives, mushrooms, peyote, psychedelics

Hallucinogens

Glue, paint thinner, gasoline, clean solvent

Inhalants

PCP and Ketamine are...

dissociative anesthetics

Heroin, methadone, morphine, Oxycodone, Opium

Opioids

Testosterone and human growth hormone

anabolic androgenic steroids

Alcohol use d/o increases the risk for...

suicide, homicide, violence, MVA

alcohol is a ___, similar to Benzos and Barbiturates

depressant

Native americans and Hispanics have higher rates of

alcohol dependence

Geriatric version screening test for alcohol use d/o

Michigan Alcoholism Screening Test-Geriatric Version (MAST-G)

Some tests that can be used to screen for al use d/o

ASSIST, CRAFFT, AUDIT

Most sensitive test for long term ETOH

GGTP, begins to decreased after 1st weeks of abstinence. AST/ALT is less specific of the LFTs

Why is insight difficult to obtain in an alcohol use d/o pt

pt is often in denial. family and friends may need to assist. group therapy may be more effective

What does a Disulfiram (Antabuse) rxn look like?

flushing, HA, throbbing, dyspnea, hyperventilation, tachycardia, hypotension, sweating, anxiety, weakness, and confusion

What tx for alcohol use d/o is an opioid antagonist that lessens the reinforcement of alcohol by decreasing the craving for alcohol. Can aid in achieving abstinence

Naltrexone (ReVia)

Tx used in alcohol use d/o AFTER abstinence is obtained. helps the pt to remain abstinent

Acamprosate (Campral)

Injectable form of Naltrexone

Vivitrol (IM)

tx for acute alcohol intoxication

supportive, nutrients (thiamine, Vit B12, folate), observation. aggression: lorazepam (Ativan) or Haldol

begins w several hours after cessation or reduction of heavy alcohol consumption. Autonomic hyperactivity, hand tremor, insomnia, nausea or vomiting, transient illusions or hallucinations, anxiety, generalized tonic clonic sz, psychomotor agitation. usually causes social impairment. not due to another condition

alcohol withdrawal

4 stages of alcohol withdrawal: MAJOR W HALLUCINATION

Stage II

alcohol w/d w DT tx

-VS q6h or more often

-observe, dec stimulation

-correct electrolyte imbalances, tx medical conditions, hydrates

-Benzo: Librium, Serax, Ativan. Geriatric w delirium: Ativan

-thiamine, folic acid, MV, Mag sulfate

-malnutrition tx

medical complications of alc use

liver dz. cardiovascular dz. nutritional deficiencies (Wernicke-Korsakoff). withdrawal seizures. DTs

thiamine deficiency. usually from chronic alc use. Nystagmus, global confusion, gaze paresis, ataxia, delirium, lethargy, confabulation. tx w thiamine and possibly Magnesium. most sx resolve. Ataxia, peripheral neuropathy, nystagmus may continue

Wernicke encephalopathy

chronic condition, usually related to alcohol dependence. large portion of the calorie intake. thiamine deficiency. retrograde and anterograde amnesia. confabulation, disorientation. tx w thiamine, clonidine/propranolol may help.

Korsakoff syndrome

Natural drug opium and derivatives

morphine and codeine

potency=strength. what is the strength of Morphine, heroin, fentanyl, and cardentanil

-Morphine=1

-Heroin=2x

-Fentanyl=100x (synthetic not pharmaceutical Fentanyl)

-Carfentanil=10,000x

how many stamp bags are in 0.1 g of opiates

1 stamp bag

how many bags are in a bundle

10 bags = 1 bundle

1 stamp bag = what in Baltimore?

1 stamp bag = cap/capsule

MAT=

medical assisted tx

CRS=

community recovery specialist

opioid intoxication sx

-drowsiness or coma

-flushing

-pupil constriction

-slurred speech

-impaired attention or memory

-euphoria, anxious dysphoria, tranquility, dec attention, memory, drowsiness

opioid intoxication has pupillary constriction, but it can also be dilation when due to...

anoxia from severe OD

opioid OD sx (MEDICAL EMERGENCY-often accidental or from use w other CNS depressants)

-respiratory depression

-unresponsive

-pinpoint pupils

-CNS depression

-seizures

-slurred speech

-hypotension

-bradycardia

opioid OD tx

-ICU and monitor VS

-IVFs

-0.8 mg Narcan (Naloxone) iV now and wait for 15 min (0.01mg for neonate)

opioid withdrawal sx

-dilated pupils

-rhinorrhea

-yawning

-N/V/D

-diffuse abd pain

-tremor

-detox and maintenance

-legally available through licensed clinics, not from primary care

-cont if hospitalized

-preferred during pregnancy

-candidates: opioid dependent > 1 yr that fail prior tx attempts

Opioid Detox: Methadone

Can be used for withdrawal and maintenance of Opioid detox. office based tx, less respiratory depression. Partial opioid agonist and opioid antagonist

Suboxone (Buprenorphine and Naloxone)

Subutex (Bupenorphine) is a

partial agonist

Sublocade (monthly SQ Buprenorphine) is a

partial agonist

Vivitrol (monthly IM Naltrexone)

Antagonist

Clonidine can be used only for tx of opioid w/drawal to relieve

N//D

Tx of sx for opioid detox w

ibuprofen, imodium, tigan, trazadone

Intoxication of sedatives, hypnotics, and anxiolytics is similar to alcohol. if combined w other CNS depressants, can cause

severe CNS depression and can be life threatening

sedative, anxiolytic, and hypnotic intoxication sx

slurred speech, incoordination, unsteady gait, impaired attention

sedative, anxiolytic, and hypnotic w/d is similar to alc w/d. it is dangerous and can lead to

-delirium and seizures

-N/V, malaise, weakness, anxiety, irritability, tremor, seizures

-some complications are life threatening and require hospitalization

What is the phenobarbital challenge test?

identifies the dose of phenobarbital needed to prevent W/D then determines amount of phenobarb to be used

what is the pure form of methamphetamine

Ice or crystal meth (synthetic)

DEA made illegal the possession and sale of chemicals to make bath salts:

mephedrone, MDPV, and methylone (Molly: synthetic MDMA purest form).

synthetic stimulant sx

chest pains, inc BP, inc HR, agitation, hallucinations, extreme paranoia, and delusions

sx of amphetamines and stimulants

euphoria, enhance mood, alertness, energy. commonly used by students, long distant truck drivers, and those desiring prolonged wakefulness

2 or more sx during or after use of amphetamine and stimulants: tachy. pupillary dilation, elevated or lowered BP, perspiration or chills, N/V, weight loss, psychomotor agitation or retardation, muscular weakness, respiratory depression, chest pain, cardiac arrhythmia

intoxication, usually resolves in 24-48 hrs

coke, blow, cane, freebase. one of the msot addictive of the commonly abused substances. addictive after one dose

cocaine

cocaine intoxication sx

-restless, anxiety, pressured speech, paranoid ideation, aggression, inc sexual interest, grandiosity, hyperactivity

-tachy, HTN, pupil dilation, anorexia, insomnia, delirium, sudden death

-snorting can lead to rebound rhinitis or perforated septum, dilated pupils, seizures

withdrawal sx of cocaine

-craving, fatigue, insomnia, inc appetite, vivid dreams, agitation

-higher addiction w smoking freebases cocaine or IV

-long term use leads to depression, suicidal ideation

therapeutic uses of cannabis/thc

glaucoma, appetite stimulant in AIDS, nausea w chemotherapy

-possibly inc risk of schizophrenia

tx for pt on cannabis/THC

-supportive

-anxiolytic for anxiety

-antipsych for delusions

psychedelics or psychotomimetic

Natural and synthetic substances

produce hallucinations, loss of reality, heightened consciousness

hallucinogens (MDMA ecstasy is an amphetamine and hallucinogen)

anxiety, depression, paranoid ideation, hallucination illusions, pupil dilation, tachycardia, palpitations, tremor, incoordination. panic rxns, HTN, hyperthermia. user can be convinced the disturbances are real. illusions, hallucinations, depersonalization, blurred vision, anxiety, paranoia

hallucinogens

3-4 hrs hallucinogens

ecstasy

Hallucinogens tx

-supportive

-safety

-diazepam can rapidly curtail hallucinogen intoxication

-psychosis and agitation: Haldol, Prolixin

-repeat experience of impaired perception after cessation: flashbacks

angel dust, is a dissociative anesthetic w hallucinogenic effects. paranoia and unpredictable violence

phencyclidine (PCP)

tx of inhalants

difficult bc cognitive impairment making participation in psychosocial tx difficult

tx of nicotine d/o

-nicotine replacement therapy

-Bupropion

-chantix

-insight therapy

Can sensitization occur w psychostimulants?

yes

What is the CAGE questionnaire?

-Have you ever felt you should CUT DOWN on drinking/drug use?

-Have people ANNOYED you by criticizing your drinking/drug use?

-Have you ever del bad or GUILTY about your drinking/drug use?

-Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover (EYE OPENER)?

Most widely used substance in US besides nicotine

Alcohol

is withdrawal from opioids often a medical emergency?

no. flulike sx, anxiety, yawning, sweating, insomnia, etc. depends on T1/2, previous dose, and rate of decrease

ritalin is a

stimulant

can amphetamines and stimulants induce a paranoid psychosis, HTN, cerebrovascular dz, MI, ischemia, tremor, ataxia, sz, coma, and death

yes

Which Criterion are "social impairment" groupings?

5, 6, 7

Which Criterion are "risky use" groupings?

8, 9

after repeated administration, a given dose of drug produces dec effect or increasingly larger doses must be given to get the effect observed w original dose

tolerance

maladaptive behavioral or psychological changes attributed to recent ingestion of a substance

substance intoxication

You must consider___in a pt w substance use dx

other psychiatric d/o

T/F genetic contribution is strong w subtance use d/o

true

all classes of addictive drugs cause direct or indirect release of ___

dopamine

What tests can be useful in confirming substance use?

urine or blood tests

General tx for substance use

-observe for possible OD

-eval for polysubstance intoxication and concomitant med conditions

-supportive tx

-manage abuse or dependence w abstinence and long term tx

-therapy, meds, etc

-12 step programs (AA)

Does marijuana, PCP, and hallucinogen withdrawal require meds?

not usually. anxiolytics may be used

Substance taken in larger amounts over a longer period of time than intended. persistent desire or unsuccessful to cut down use. great deal of time is spent obtaining the substance, using it or recovering from the effects. craving, desire. recurrent use results in failure to fulfill obligations at work, school, home. Continued use despite social or interpersonal problems caused by the effects of alcohol. Obligations given up bc of use. Use continued knowing there is a persistent or recurrent physical or psychological problem caused by use. Tolerance, or withdrawal.

Alcohol use d/o diagnostic criteria