BH E2- Substance Use Disorders Pt. 1

What is a nonmedical term that denotes psychological and/or physical dependence that results in substance seeking behavior?

Addiction

What term describes the physiologic changes that occur with drug use and result in withdrawal symptoms with termination/decrease in use?

Physical dependence

What term refers to craving or desire for the substance independent of physiologic withdrawal symptoms?

Psychological dependence

What is a better term to use since physical and psychological dependence occur together?

Substance dependence

The following criteria is for what condition?

• Substance use results in impairment with ≥ 3 of the following within a year

  • 1. Tolerance

  • 2. Withdrawal

  • 3. Use of increasingly larger amounts over longer period than desired

  • 4. Unsuccessful efforts to stop or decrease amount of use

  • 5. Significantly large amounts of time spent in attempts to acquire/use/recover

  • 6. Social, occupational, or recreational impairment

  • 7. Continued use of substance despite awareness of adverse consequences

Substance dependence

What is the phenomenon in which there’s either a decreased effect over time when the same amount of substance is used or increasingly larger doses must be used to obtain effect seen with original dose?

Tolerance

What is the phenomenon in which there is a need to use the substance to relieve or avoid physical symptoms associated with deprivation of it?

Withdrawal

The following criteria is for what condition?

• use of a substance does not meet criteria for dependence, but results in impairment with ≥ 1 of the following w/in a year:

  • 1. Fails to meet obligations

  • 2. Repeatedly uses substance in hazardous situations (driving)

  • 3. Recurrent substance related legal problems

  • 4. Continues to use substance despite experiencing interpersonal/social problems

Substance abuse

What state has a higher than national average for substance use/abuse?

Florida

What is the MC prescription that is abused?

Narcotics/opioids (followed by stimulants, anxiolytics)

A person is more likely to become dependent on drugs if they start at what age?

≤ 14 y/o

Who is drug use/abuse MC in?

Americans in their late teens & twenties (but inc in 50s)

Who has similar addiction rates as the general public for alcohol/illegal drugs but is 5x more likely to misuse/abuse prescription drugs?

Providers

What causes voluntary drug using behavior to transform compulsive drug use?

Changes in the structure and neurochemistry in brain of the drug user

What do patients with substance use, abuse, or dependence have a predisposition to?

Antisocial personality disorder

Who is 20x more likely to die by suicide than the general population?

Substance users

The following criteria is for what condition?

• problematic pattern of alcohol use leading to clinically significant impairment or distress w/ ≥ 2 of the following in 12 mos:

  • ETOH taken in larger amounts over longer period of time than was intended

  • persistent desire / unsuccessful efforts to cut down

  • A lot of time spent to obtain/use/recover from ETOH

  • craving or strong desire to use ETOH

  • recurrent ETOH use results in failure to fulfill major obligations

  • continued use desire problems caused/wrosened by EOTH

  • important activities given up/reduced by use

  • recurrent use in physically hazardous situations (DUI)

  • continues use despite having persistent problems

  • tolerance sx

  • withdrawal sx

Alcohol use disorder

How many symptoms are present in mild alcohol use disorder?

2-3

How many sx are present in moderate alcohol use disorder?

4-5

How many sx are present in severe alcohol use disorder?

≥ 6

What is considered a moderate drinker?

2 drinks/day in men, 1 drink/day in women

What is considered a heavy drinker?

15+ drinks/week in men, 8+ drinks/week in women

What is considered binge drinking?

Men ≥5 drinks & women ≥4 drinks on same occasion

What is considered heavy binge drinking?

Binge drinking on at least 5 separate days in the past month

When do most Americans try alcohol for the first time?

Early-middle teens

Which substance has the highest rate of dependence and abuse?

Alcohol

What are risk factors for suicide in a patient with alcohol use disorder?

Previous attempts (MC), presence of major depressive episode, weak psychosocial support systems, unemployment, living alone

25-50% of all people with alcohol use disorder also meet the diagnostic criteria for what condition?

Anxiety (frequently phobias & panic disorders)

What is the etiology of alcohol use disorder?

Genetic influences for 60% of RF & environment for 40%

When is the peak blood concentration of alcohol reached?

30-90 minutes (faster with rapid drinking or 15-30% alc content)

What defense mechanisms does our body have against alcohol?

Inc alc concentration in stomach → mucus secreted & pyloric valve closes to slow absorption/keep alcohol from passing into SI → large amounts can remain unabsorbed for hours → pylorospasm & relaxed LES causes N/V

Where is most of ETOH aborbed?

Small intestine

What behavioral effects does alcohol have?

Net result = depressant

0.05% = thought, judgement, restraint loosened

0.1% = voluntary motor actions become clumsy

0.2% = entire motor area of brain depressed & emotional behavior affected

0.3% = confused or stuporous

0.4-0.5% = coma

Higher levels affect primitive centers of brain that control breathing/HR → death secondary to depression or aspiration

How does alcohol affect sleep?

Increases ease of falling asleep but decreases REM stage and causes sleep fragmentation, with more & longer episodes of awakening

How does alcohol affect the liver?

Accumulation of fats & proteins → enlarges → development of alcoholic hepatitis & cirrhosis

How does alcohol affect the GI system?

Esophagitis, gastric ulcers, varices, pancreatitis, cancer, vitamin deficiencies (B1- thiamin, B12), anemia

The following clinical features are seen with what condition?

• inability to cut down/stop drinking

• binges

• amnestic periods while drinking (blackouts)

• continuation of drinking despite serious physical disorder that the person know is exacerbated by alcohol use

• drinking non beverage alcohol such as rubbing alcohol

Alcohol dependence/abuse

What is the CAGE screening for alcohol dependence?

asked to cut down, annoyed by criticism, felt guilty about drinking, & eye opener

each question 1 pt, score of ≥2 clinically significant

What are the 3 general steps involved in treating alcoholism after diagnosis?

Intervention, detoxification, & rehabilitation

What is a program aimed merely at controlling acute withdrawal & consequences of recent alcohol use?

Detoxification

How does intervention work?

Problem of denial must be faced, preferably with family members present, & must also deal with enabling behavior

What 3 major components are included in outpatient rehabilitation for alcohol use disorder?

Repeated efforts to increase & maintain high levels of motivation for abstinence (counseling 3x/wk, AA), help pt readjust to lifestyle of free alcohol (sober peer group), & prevent relapse (coping methods)

When is inpatient rehabilitation recommended for alcohol use disorder?

Failed outpatient rehab or comorbidities that require hospitalization

What are the 12 steps of Alcoholics Anonymous (AA)?

Surrendering: surrender, higher power, decision

Confessing: self assessment, sponsor, readiness to change, humility, taking responsibility, restitution & amends

Maintaining: balance, connectedness, helping others

What medications can be used to treat alcohol use disorder?

1st line: Naltrexone (Vivitrol)

2nd line: Disulfiram (Antabuse)

What are CIs to naltrexone (vivitrol)?

Tramadol or opioids (must be drug free for 10 days w/ UA), acute hepatitis, liver failure (*monitor LFTs)

What drug is used to discourage alcohol use by causing severe N/V when alcohol is consumed (2nd line treatment)?

Disulfiram (Antabuse)

The following criteria is for what condition?

• recent ingestion of ETOH

• clinically significant problematic behavioral or psychological changes that developed shortly after ingestion

  • Ex: inappropriate sexual or aggressive behavior, mood liability, impaired judgement

• ≥1 of the following

  • slurred speech, incoordination, unsteady gait, nystagmus, impairment of attention or memory, stupor or coma

Alcohol intoxication

The following criteria is for what condition?

• cessation/reduction of ETOH that’s been heavy or prolonged

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

  • autonomic hyperactivity- sweating or pulse > 100 (6-36 hrs)

  • inc hand tremor (6-36 hrs)

  • insomnia

  • N/V

  • transient visual, tactile, auditory hallucinations )24-72 hrs)

  • psychomotor agitation

  • anxiety (6-36 hrs)

  • generalized tonic clonic seizure (w/in 6-48 hrs)

• sx cause significant distress or impairment in functioning

Alcohol withdrawal

When do mild alcohol withdrawal sx begin?

W/in 6 hrs of last drink & peak w/in 36 hrs

*tremor, tachycardia, sweating, HTN, anxiety

What is the most severe form of alcohol withdrawal syndrome that occurs 48-96 hrs after last drink & is considered a medical emergency as it can lead to death if untreated (usually from PNA, renal dz, hepatic insufficiency, or HF)?

Delirium tremens (DT)

What are symptoms of DT?

Acute organic psychosis characterized by confusion, tremor, sensory hyperacidity, visual hallucinations, autonomic hyperactivity, diaphoresis, dehydration & seizures

Why can’t heavy drinkers stop abruptly?

Withdrawal & risk of DT → refer for medical detox & B1 injections, obtain CIWA

Which form of THC causes more euphoria, high & anxiety- delta 9 or delta 8?

Delta 9 THC (dronabinol)

The following criteria is for what condition?

• problematic pattern of cannabis use leading to clinically significant impairment or distress w/ ≥ 2 of the following w/in 12 mo period:

  • same criteria as other substance disorders

• mild: 2-3 sx

• mod: 4-5 sx

• severe: ≥ 6 sx

Cannabis use disorders

When do the effects of cannabis onset when it is smoked?

Within seconds, peaks in 30 minutes, last a couple hours

What psychical & psychological effects does cannabis have on the body?

Altered senses & time perception, mood changes, impaired movement & memory, temporary hallucinations & paranoia

What harmful & long term effects does cannabis use have?

Respiratory impairment & tachycardia, decreased mental & physical function

What form of cannabis is most dangerous to the lungs?

Smoked (more so than cigs)

How can a patient get medical marijuana?

Physician must certify that pt has qualifying medical condition (“certified”, not prescribed)

The following criteria is for what condition?

• recurrent use of cannabis

• clinically significant problematic behavioral/psychological changes that develop shortly after use

  • ex: impaired motor coordination, euphoria, anxiety, sensation of slowed time, social withdrawal, impaired judgement

• ≥2 of the following w/in 2 hrs of cannabis use

  • conjunctival injection, inc appetite, dry mouth, tachycardia

Cannabis intoxication

How does cannabis intoxication affect an individual?

Heighten’s sensitivities to external stimuli, reveals new details, makes colors seem brighter & richer, subjectively slows appreciation of time, and may cause depersonalization / derealization in high doses

What are the most serious potential adverse effects of cannabis use?

High risk for chronic respiratory dz & lung CA d/t inhaling carcinogenic hydrocarbons

The following criteria is for what condition?

• cessation of cannabis use thats been heavy or prolonged

• ≥ 3 of the following w/in 1 week of cessation

  • irritability, anger, aggression

  • nervousness or anxiety

  • sleep difficulty (insomnia, disturbing dreams)

  • dec appetite or wt loss

  • restlessness

  • depressed mood

  • discomfort from abd pain, shakiness/tremors, sweating, fever, chills or HA

Cannabis withdrawal

What is the treatment for cannabis use?

Abstinence & support from individual, family or group therapies

What agents are stimulants?

Adderall (dextroamphetamine), concerta or ritalin (methylphenidate HCL), anabolic steroids, ecstasy, cocaine, amphetamines, methamphetamines

The following criteria is for what condition?

• problematic pattern of amphetamine type substance, cocaine, or other stimulant leading to significant impairment or distress w/ ≥ 2 of the following w/in 12 month period:

  • same sx as other substance disorderes

• mild: 2-3 sx

• moderate: 4-5 sx

• severe: ≥ 6 sx

Stimulant use disorder

The following criteria is for what condition?

• recurrent use of stimulant

• significant problematic behavioral/psychological changes that developed shortly after use

  • ex: euphoria, affect blunting, changes in sociability, hyper vigilance, interpersonal sensitivity, anxiety, tension, anger, impaired judgement

• ≥ 2 of the following develop shortly after use

  • tachy/bradycardia, mydriasis, inc or dec BP, perspiration or chills, N/V, evidence of wt loss, psychomotor agitation or retardation

  • muscular weakness, resp depression, CP, arrhythmias,

  • confusion, seizure, dyskinesias, dystonias, or coma

Stimulant intoxication

The following criteria is for what condition?

• cessation/reduction of prolonged stimulant use

• dysphoric mood (sadness/heaviness) & ≥2 of the following w/in few hours-several days of cessation

  • fatigue

  • vivid unpleasant dreams

  • inc appetite

  • psychomotor agitation or retardation

• sx cause significant distress or impairment in functioning

Stimulant withdrawal

What drug is a neuro stimulant that can be smoked, injected, or snorted?

Cocaine

What are other names for cocaine?

Blow, coke, snow, crack, rock, speedball (injected heroin & cocaine)

What are the MC comorbid psychiatric disorders to cocaine use?

MDD, bipolar II, anxiety, antisocial personality disorder

What physical & psychological effects does cocaine have on the body?

Euphoria, hyperactivity, inc alertness, hypersensitive, irritability & paranoia

What harmful effects does cocaine have on the body"?

Vasoconstriction, mydriasis, N, hyperthermia, tachycardia, restlessness, tremors

What long term effects does cocaine have on the body?

Malnutrition, infx (HIV, hepatitis), & CV disease

Describe the neuropharmacology of cocaine use

Behavioral effects almost immediate (< 1 min for IV or smoked & lasts ~20 min; 15 min for nasal & lasts ~ 1 hr)

Tolerance/sensitivity develops to various effects with repeated use

When can psychological dependence to cocaine develop?

After single use

The following physical sx are associated with intoxication of what substance?

• tachycardia, hyperthermia, HTN, seizures, diaphoresis, mydriasis

Cocaine intoxication

What symptoms are seen in post intoxication depression (“crash”) from cocaine withdrawal?

Dysphoria (sadness/heaviness), anhedonia (inability to feel pleasure), anxiety, irritability, fatigue, hyper somnolence, sometimes agitation

When do withdrawal sx with mild-mod cocaine use end?

w/in 18 hrs

How long do withdrawal sx last with heavy cocaine use (cocaine dependence)?

Up to a week, peaks in 2-4 days

What adverse effects are associated with nasal cocaine use?

Nasal congestion, serious inflammation, swelling, bleeding, ulceration of nasal mucosa, & perforation of nasal septa (long term use)

What adverse effects are associated with IV cocaine use?

Endocarditis, transmission of HIV, hepatitis

What is a hemorrhagic pneumonitis caused by smoking crack that causes CP, cough, dyspnea, hemoptysis, or bronchospasms, B/L infiltrates on CXR & eosinophilia on CBC?

Crack lung

What cardiac adverse effects are seen with cocaine use?

STEMI/N-STEMI, vtach, v fib, SVT, holiday heart, afib, & acute coronary ischemia are MC

Cardiomyopathies can develop if long term

What is the treatment for cocaine related disorders?

Complete or partial hospitalization to remove pt form usual settings they obtained/used the drug & to overcome intense cravings

CBT, hospitalization & outpatient therapy to prevent relapse & achieve abstinence

What disorders have amphetamines been FDA approved to treat?

ADHD & narcolepsy

What are street names for amphetamines?

Bennies, uppers, speed, black beauties, amped, cartwheels, super jellies, hearts, set ups, sparkles, dexies, oranges

What are street names for methamphetamines?

Ice, crystal, crystal meth, chalk, crank

What are the major prescription amphetamines in the US?

Dextroamphetamine (Dexedrine), dextroamphetamine-amphetamine salt (Adderall), methylphenidate HCL (Ritalin or concerta)

What can an overdose of amphetamines cause?

Severe CV event, psychosis, & death

In what population is amphetamine use MC in?

College students, early 20s (students studying for exams, long distance truck drivers, business people w/ important deadlines, athletes in competition w/o drug testing)

The following sx can be seen with intoxication of what substance?

• palpitations, tachycardia, inc BP, tachypnea

• mydriasis, blurred vision

• dry mouth, unpleasant tastes, anorexia

• rash, diaphoresis, alopecia

• rhabdomyolysis, tremors

• psychotic episode (delusions)

Amphetamine intoxication

What withdrawal sx (crash) are seen after amphetamine intoxication?

Anxiety, tremulousness, dysphoric mood, lethargy, fatigue, HA, profuse sweating, muscle or stomach cramps, insatiable hunger

most serious → depression, can cause SI

How long do amphetamine withdrawal sx last?

Peak in 2-4 days, resolved in 1 week

What is the treatment for amphetamine use?

Inpatient setting & use of multiple therapeutic methods (individual, family, group therapy) necessary to overcome powerful cravings & achieve lasting abstinence

What drug?

• Easily & inexpensively made from Sudafed in simple labs created in homes, garages, vehicles

• Inhaled: equally intense & longer lasting high than coke (t1/2 = 12 hrs)

• IN, IV: rapidly absorbed w/ rapid onset of action < 1 hr

• PO: rapidly absorbed w/ rapid onset w/in 1 hr

Methamphetamines

In what age group is methamphetamine use MC in?

26-34 y/o

How long does methamphetamine intoxication last?

Sx mostly resolved after 24 hrs, completely resolved after 48 hrs

What harmful effects are seen with methamphetamines?

Hyperthermia, tachycardia, restlessness, anorexia, tachypnea, irregular heartbeat, inc BP