Exam 3: substance use and disorders

intoxication

reversible, substance-specific

-management of acute intoxication is common

-substance use can result in health and social consequences without being a disorder

criteria for substance use disorders (SUDs)

DSM 5: using a substance despite significant problems it's causing

-cognitive, behavioral, and physiological symptoms

-impaired control: inability to cut down, craving

-social impairment: can't fulfill roles

-risky use: using in physically hazardous situations

-pharmacological criteria: tolerance and withdrawal

tolerance

no longer responding to drug compared to initially after consistent use

-time for tolerance to build can vary

-those using frequently no longer using to get high, but to stop feeling sick

withdrawal

substance-specific physiologic symptoms occurring with lapse in consistent use

-mild or life-threatening

overdose

-mild to life threatening

-accidental or intentional

-tolerance can affect level necessary for overdose (less likely with high tolerance)

biological factors and SUDs

-heritability in most SUDs

-40-60% risk for alcohol use disorder is genetics, 70-80% in cocaine and opiates

-decreased risk: inactive alcohol dehydrogenase -> causes unpleasant symptoms when drinking -> less risk of alcohol abuse (asian descent)

neurobiological factors and SUDs

-addictive substances hijack brain's reward center -> unnatural release of dopamine

-anhedonia: inability to enjoy previously pleasurable things, in this case because chronic dopamine imbalance diminishes natural reward response

-low baseline NT activity = increased risk

-process addictions (shopping, gambling, porn)

psychological factors and SUDs

-high comorbidity of SUDs and mental illness

-using CBT and DBT can help in these cases

social factors and SUDs

-social determinants

-poverty, poor education, neighborhood disadvantage

-environmental exposure through proximity to drug markets

-elevated chronic stress

-addiction perpetuates this: compromises social stability

alcohol

CNS depressant

-rapidly absorbed through GI

-enhances GABA

-motor incoordination, impaired judgement, sedation, coma

-physical dependence -> withdrawal can be life threatening

alcohol withdrawal symptoms

-autonomic hyperactivity: tachy, hyperhidrosis

-hand tremor

-insomnia

-transient visual, tactile, and auditory hallucinations or illusions

-n/d

-psychomotor agitation

-anxiety

-grand mal seizures

chronic alcohol use and the heart

cardiomyopathy, HTN, arrhythmias, stroke

chronic alcohol use and GI

esophageal varices, gastritis, ulcers, malnutrition

-wenicke-korsakoff syndrome

chronic alcohol use and the liver

fatty liver, cirrhosis, alcohol-associated hepatitis -> ascites

chronic alcohol use and the pancreas

pancreatitis

chronic alcohol use and cancer

esophageal, stomach, mouth, throat, breast, colorectal

-even in low-risk use

wernicke-korsakoff syndrome

from prolonged heavy alcohol use, brain damage caused by thiamine (B1) deficiency due to malnutrition and poor nutrient absorption

-wernicke's encephalopathy: severe and short-lived, muscle incoordination, and confusion

-korsakoff's syndrome (psychosis): chronic, appears when wernicke's subsides, learning/memory problems, confusion, difficulty walking

-early intervention with PO/IV thiamine can prevent worsening

opioids (heroin, synthetic opioids, Rx painkillers)

bind to opioid receptors -> euphoria, pain relief, decreased CNS and NE

-opioid intoxication: nodding off, impaired attention/memory, incoordination (CNS), n/v, dry mouth, constipation (NE)

-intox assessment: bradypnea, hypotension, constricted pupils

opioid strengths in relation to morphine

heroin = 3x, hydromorphone = 5x, fentanyl = 100x, isotnitazene = 800x, carfentanil = 1000-10,000x

opioid deaths and types of opioids

prescribed opioids and heroin = low risk

synthetic opioids = high risk

opioid overdose signs and treatment

emergency

-respiratory arrest, coma/unresponsive, pinpoint pupils (miosis)

treatment

-1st line: verbal and physical stimulation

-2nd line: naloxone (IM or IN) + rescue breaths or ventiltion

-CPR if no pulse

-compassion -> frightened/disoriented after waking up

-excess naloxone can precipitate withdrawl symptoms

-may return to opioid intox after nalozone wears off

opioid withdrawal

occurs 12-36 hours after cessation

-tachycardia, HTN, hyperthermia, diaphoresis, yawning, runny nose

-stomach cramping, n/v, insomnia, anxiety, agitation

think hyping you up + yawning

opioid chronic health impacts

often due to injection drug use -> endocarditis, hepatitis, HIV

-fatal overdose

-GI issues -> constipation, malnutrition

stimulants (Rx stimulants, meth, crack/cocaine)

elation, exhilaration, alertness

-anxiety, paranoia, hallucinations, restless, irritable, reduced appetite, insomnia

-vitals/assessment: tachycardia, HTN, dilated pupils, swearing, flushing, bruxism (grinding teeth, clenched jaw)

cocaine (powder or crack)

-shorter high (10-30 mins)

-increased change of nasal cavity damage

amphetamine-type (meth, dexedrine)

-longer effect (12 hrs max)

-dental issues more common with meth -> gum disease, bruxism

stimulant contamination

contaminantion with opioids can lead to opioid overdose

stimulant overamp

cardiac/cardiovascular complications

-heart attack, stroke, arrhythmias

-seizures

-hyperthermia, heat stroke (increased metabolic actvity and vasoconstriction)

stimulant withdrawal

tiredness, vivid nightmares, increased appetite, insomnia or hypersomnia, agitation, depression/suicidal ideation

-less likely to be emergent

cannabis

euphoria, relaxation, slowed/distorted sensory perception

-anxiety, panic, increased or decreased appetite, memory issues

-assessment: tachy, conjunctival injection (red eye), impaired coordination

cannabis long-term use

psychosis, chronic lung issues, cannabinoid hypremesis syndrome

synthetic cannabinoids (K2, spice)

10-100x more potent

-vomiting/aspiration, delirium, intense agitation, seizures, chest pain, laboured breathing, death

classic hallucinogens

LSD, DMT, psilocybin

-serotonin agonists

-synthetic or natural

-illusions, synesthesia, paranoia

-assessment: tachy, diaphoresis, pupil dilation

empathogens

MDMA - exctasy, molly

-release of seratonin and dopamine and NE

-elevated mood, pleasure, tactile sensitivity

-assessment: hyperthermia, heat stroke, seratonin syndrome, bruxism (jaw clenching)

-post-use depression/anxiety

dissociative anesthetics

ketamine, PCP, nitrous oxide

-detachment from current environment (k hole, out of body), pain relief, memory loss, psychosis (PCP especially)

-ketamine: GI and bladder issues

-whippits/galaxy gas (nitrous oxide): b12 deficiency from use causes neurological and blood cell issues, asphyxiation

polysubstance use

some okay to mix, some not

greatest risk:

-benzos + opioids (similar effect)

-alcohol + benzos (similar effect)

-alcohol + opioids (similar effect)

-cocaine + opioids (bc longer acting opioid effect covered up initially by cocaine effect)

nitazenes

-highly potent synthetic opioids

-nalaxone can be used

xylazine

vet tranquilizer (tranq dope)

-non-injection site wounds: due to vasoconstriction in vascular smooth muscle -> tissue toxicity

-naloxone does NOT work

7-OH

available in stores in some states (not WI)

-synthetic, potent version of mitragynine

-opioid receptor action

injection drug use

increased risk of acquiring and transmitting bloodborne viruses (HIV, hepatitis C) through syringes or equipment (like cooking equipment)

-localized and systemic infections -> cellulitis, abscesses, endocarditis, sepsis

-significant risk of fatal and non-fatal overdose

-damage and scarring to veins -> venous insufficiency, poor access

injection drug use assessment

-history to assess withdrawal risk and tolerance

-skin/vascular: look at injection sites for signs of infection and missed hits/skin popping (can lead to abscesses)

-vitals/labs: tachy, HTN, fever, increased WBC -> indicate withdrawal or infection