Substance Use Disorders - Crouse

Learning Objectives

• review patient first language

• Describe cycle of addiction

  • define misuse, diversion, and dpeendence

• List most common abuse misuse symptoms

• Summarize DSM5 criteria for SUD

  • mild, moderate, severe

• Identify role of drug screens

• List common health comorbidities

• Identify CYP1A2 DDIs with smoking and psych medis

• Identify psych presentations of stimulant use and toxicities

• Role of non-pharmacological treatment in SUD

We must do this to obtain a proper SUD history

Collect of the PPCP!!!!

• nonjudgmental pattitude needed

• Collect what?

  • Usage patterns

  • problems resulting from SUD

  • Support systems (family, friends, etc)

  • Family history?

  • Childhood or adolescent abuse?
    
    

What are the adolescent childhood experiences? (ACE’s)

• Physical or sexual abuse

• Physical or emotional neglect

• Separation or divorce

• family member with illness or h/o suicide

• Family member addicted to drugs or alcohol

• family member in prison

• Witnessing a parent being abused

ACE scores have been linked to higher rates of…

• substance misuse

• CV disease

• cancer

• lifetime hx of depression

Important patient-first language for talking about SUD

• “use”

• “misuse”

• “diversion”

What brain neurotransmitter plays a central role in “reward” pathway associated with addiction/SUDs?

Dopamine!!

3 stages of the addiction cycle

1. Binge and Intoxication

   1. feeling euphoric, feeling good, escaping dysphoria

2. Withdrawal and negative effect

   1. Feeling reduced energy, reduced excitement, depressed, anxious, restless

3. Preoccupation and anticipation

   1. Looking forward, desiring drug, obsessing and planning to get drug

What are the behavioral changes in substance use disorder STAGES OF ADDICTION?

• starts with voluntary action, abstinence and contrasted drug taking

• then start taking drug when not intended, some trouble stopping, taking more than intended

• THEN impulsive action, relapse, compulsive consumption

What is the DSM-5 criteria for SUD?

1. Essential Feature of Substance Dependence requires continued use despite adverse problems related to use of the substance

2. TWO (2) of the following MUST occur during a 12-month period

3. Severity is classified by number of symptoms present

4. Symptoms part 1

   1. Is taken in larger amounts or over a longer period than intended

   2. Large amount of time spent trying to obtain, sue, ercover

   3. Craving to use

   4. recurrent use — failure to fulfill obligations at work, school, or at home

   5. Despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of substance; they continue to use the substance

   6. Important social, occupational, or recreational activities are given up or reduced because of the use of the substance.

DSM-5 criteria for SUD — symptoms part 2

part 2

• use of substance in physically hazardous conditions

• continued despite knowledge of harm or problem

• Tolerance

• Withdrawal

What are the levels of SUD pertaining to the DSM-5 criteria?

• 2-3 DSM criteria = MILD

• 4-5 DSM criteria = MODERATE

• > 6 DSM criteria = SEVERE

Why are Urine drug screens preferred for testing for SUDs?

Easy, PLUS easy to detect metabolites after a few days

Urine Drug Screens are used to rule out

• SUD

• Substance Use induced mood disorder (SIMD)

  • mania or depression

• SUDs used for contingency management or target outcomes (positive reward for doing expected behaviors)

Urine Drugs screen per drug and their UDS outcomes

1. Cocaine

   1. Rarely false positives — so usually positive!!

2. Benzo’s

   1. Detects diazepam metabolites

   2. False negatives with lorazepam and clonazepam

3. Opioids

   1. Detects pure opioids/morphine

   2. Many limitations on false limitations

4. Amphetamines

   1. Bupropion false positive

Common psychiatric co-morbidities with SUDs

• GAD

• MDD

• PTSD

• ADHD

• Eating disorders (laxative abuse)

• Insomnia

• Borderline PDO

Smoking and mental health

• Persons with mental health disorders are much more likely to smoke

  • schizophrenia patients often smoke

• Smoking is a CYP1A2 inducer

  • Clozapine and Olanzapine are impacted by smoking

• Landmark trial —- EAGLES trial Took BBW off chantix pertaining to mental health conditions

  • they were scared that chant would cause dreams, etc.. - EAGLES proved it was not important

Illicit substances in SUDs?

• Marijuana and synthetic cannabinoids

• Synthetic cathinoes

• Cocaine

• Nonmedical use of Drugs

• Stimulants and Meth

• Halucinogens

• Nonmedical use pain relievers and Heroin

• Sedatives and Tranqs

• Inhalants

Cocaine and crystal meth routes of misuse

• Intranasal

• Smoking/inhalation

• Intravenous/injection

Prescription stimulants routes of misuse

• Oral tablets

• Crush and snort intranasal

• Intravenous?

Cocaine intoxication steps

• Mentally alert

• Reduce appetite

• Euphoric

• Energetci

BP effects

• increase BP and HR

Too much

• paranoia

• Anxious, restless

Crystal meth intoxication effects

Acute effects

• Euphoric rush

BP effects

• Rapid irregular HR

Rx stimulants intoxication effects

• Increased focus/concentraion

• Improved energy

• Weight loss

General ratio of Stimulant toxicities

FDA Treatment of SUDs by substance

1. Cocaine == No FDA approved indication

2. Meth == No FDA approved indication

3. Opioids == Methadone, Buprenorphine, Naltrexone

4. Cannabis == No FDA approved indication

5. Alcohol == Naltrexone, Acamprosate, Disulfiram

6. Nicotine == NRT, Varenicline, Bupropion