substance related and addictive disorders

a problematic pattern of use causing clinically significant impairment/distress with ≥2 criteria in 12 months

-criteria included: impaired control, social impairment, risky use, pharm tolerance/withdrawal

DSM 5 definition of substance use disorder

mild (2-3), moderate (4-5), severe (≥6)

# of criteria met with mild, moderate, and severe ssubstance abuse disorder

poor insight

EX:

Minimizing ("I can stop anytime")

Rationalizing ("I need it to sleep/study")

Blaming others ("My partner is the problem")

Inconsistent stories, missing meds, early refills, "lost prescriptions"

Functional decline despite claims of "fine"

"Denial" of substance use problem indicates

mnemonic: FAST

Frequency, amount, route (snort, smoke, IV)

Abstinence attempts + withdrawal symptoms

Seizures/DTs/overdoses; blackouts

Time course + triggers + tolerance

high yield history to take in substance abuse history

Risk highest in adolescents/young adults; ↑ with trauma history, psychiatric illness, social instability

group at highest risk of substane abuse

alcohol/cannabis (self-medication)

depression/anxiety often paired with this substance use

alcohol/cocaine

bipolar is often paired with this substance use

alcohol/ opioids

PTSD is often paired with this substance use

nicotine/cannabis/stimulants

schizophrenia often paired with this substance use

Cut down: "Have you felt you should cut down?"

Annoyed: "Have people annoyed you by criticizing your drinking?"

Guilty: "Have you felt bad or guilty about drinking?"

Eye-opener: "Do you drink first thing in the morning?"

define the CAGE screening tool for alcohol use disorder

≥2 suggests alcohol problem.

how to interpret CAGE criteria

AUDIT / AUDIT-C

alcohol screening tool more sensitive than CAGE

↑ Dopamine in mesolimbic pathway (reinforcement)

GABA/glutamate adaptation → tolerance/withdrawal

neurobiologic etiology of alcoholism

hyperthermia, arrhythmia, stroke

signs of stimulant intoxication (cocaine/amphetamines)

withdrawal uncomfortable but usually not fatal

prognosis of opiate withdrawal

euphoria, agitation, mydriasis, tachycardia, HTN, chest pain, paranoia; risk MI/stroke

signs of cocaine intoxication

benzodiazepines, cooling, IV fluids; treat chest pain/MI per protocol (avoid pure beta-blocker monotherapy in acute intoxication)

treatment of cocaine intoxication

beta blockers

avoid this blood pressure med in management of chest pain in cocaine intoxication

"crash" → depression, hypersomnia, increased appetite, anhedonia

presentation of cocaine withdrawal

supportive, monitor suicidality

management of cocaine withdrawal

similar to cocaine + severe agitation, psychosis, hyperthermia

presentation of amphetamine intoxication

benzodiazepines, antipsychotic if severe psychosis, aggressive cooling/hydration

tx of amphetamine intoxication

perceptual distortions, panic, mydriasis, tachycardia; possible "bad trip"

signs of hallucinogen (LSD/psilocybin) intoxication

quiet environment, reassurance, benzos for severe anxiety

tx for hallucinogen intox

no

are there withdrawal symptoms associated with halllucinogens?

irritability, anxiety, insomnia, ↓ appetite

signs of cannabis withdrawal

violent agitation, nystagmus, analgesia, HTN, hyperthermia, psychosis

presentation associated with PCP (phencyclidine)

PCP

intoxication associated with nystagmus

benzodiazepines, restraints if needed, cooling; antipsychotic cautiously (seizure/QT risk)

tx of PCP intoxication

CNS depression, respiratory depression, hypotension

signs of barbiturate intoxication

airway/ventilation support, ICU care

tx of barbiturate intoxication

tremor, agitation, seizures → can be fatal

presentation of barbiturate withdrawal

controlled taper (often phenobarbital protocol), ICU if severe

mgmt of barbiturate withdrawal

heroin, oxycodone, fentanyl

name the main characters in the opiate family

miosis, respiratory depression, sedation, bradycardia

signs of opiate intoxication

naloxone, airway support; treat aspiration risk

tx of opiate intoxication

lacrimation, rhinorrhea, yawning, piloerection, diarrhea, cramps, mydriasis

presentation of opiate withdrawal

buprenorphine or methadone, clonidine/lofexidine for autonomic symptoms, symptomatic meds

tx of opiate withdrawal

irritability, anxiety, increased appetite, cravings

symptoms of nicotine withdrawal

sedation, ataxia, respiratory depression (worse with alcohol/opioids)

signs of benzo intoxication

supportive/airway; flumazenil rarely (seizure risk, chronic use, mixed overdoses)

treatment for benzo intoxication

flumazenil

rescue therapy for benzo overdose

anxiety, tremor, insomnia, seizures, delirium

presentation of benzo withdawal

slow taper (often long-acting benzo), inpatient if severe

tx of benzo withdrawal

tremor, anxiety, tachycardia

symptoms of alcohol withdrawal in first 6-12 hours

hallucinosis, seizures

symptoms of alcohol withdrawal in 12-48 hours

DTs (delirium, fever, autonomic instability)

symptoms of alcohol withdrawal in 48-96 hours

6-12h: tremor, anxiety, tachycardia

12-48h: hallucinosis, seizures

48-96h: DTs (delirium, fever, autonomic instability)

prognosis of untreated alcohol withdrawal

delirium tremens

a psychotic condition typical of withdrawal in chronic alcoholics, involving tremors, hallucinations, anxiety, and disorientation.

benzodiazepines (symptom-triggered CIWA), thiamine before glucose, fluids/electrolytes; ICU for DTs

treatment of alcohol withdrawal

Elderly (falls, delirium)

OSA/COPD

Substance use history

benzos are relatively contraindicated in this class of patients

alcohol and benzo withdrawal

-both treated with benzos

substance withdrawals that can KILL!

PCP

nystagmus + violence + analgesia indicates intoxication with

benzos first

treament of cocaine/amphetamine intoxication starts with

substance-induced psychosis

______________ must be ruled out before diagnosing schizophrenia/bipolar