Substance Use Disorders

Describe Substance Use Disorders

• Harmful consequences

• Impact on Treatment

Harmful consequences

• Biological toxicity

  • Cancer, liver toxicity, fetal alcohol syndrome

• Disturbing or dangerous behavior

  • Embarrassing actions, arguments, physical violence, vehicle crashes

• Relationship problems

  • Isolation from friends and family, divorce

• Legal problems

  • Incarceration

---

Impact on Treatment

• Affect prognosis/treatment response of other mental disorders

  • Often respond less well to treatment

  • Associated w/ poor compliance

• Characteristics are manifested in the treatment relationship

  • Some may become overly dependent

  • They may not follow recommendations

  • May experience conflict about getting well

  • More likely to be dissatisfied

When is it considered unhealthy alcohol abuse?

What dis the Dx Criteria for Substance Abuse Disorder

Substance Use Disorder Dx Criteria: 2 w/in 12 month period:

• 1. Substance often taken in larger amounts or over a longer period than intended

• 2. Persistent desire or unsuccessful attempts to cut down or control use

• 3. A great deal of time is spent in activities necessary to obtain, use or recover from its effects

• 4. Craving, or strong desire or urge to use 

• 5. Recurrent use -> failure to fulfill major role obligations 

• 6. Continued use despite having persistent social/interpersonal problems caused by effects of substance

• 7. Important social, occupational, or recreational activities are given up/reduced because of use

• 8. Recurrent use in situations in which it is physically hazardous

• 9. Use is continued despite knowledge of having persistent/recurrent problems associated w/ use 

• 10. Tolerance, as defined by either of the following:

  • need for markedly increased amounts to achieve intoxication or desired effect

  • markedly diminished effect with continued use of the same amount 

• 11. Withdrawal, as manifested by either of the following:

  • . characteristic withdrawal syndrome 

  • closely related substance, is taken to relieve/withdrawal

[REVIEW] CAGE

Describe Alcohol Use Disorder

1. Hints for Diagnosis

2. Medical Complications

3. Psychiatric and Social Complications

4. Alcohol Intoxication Symptoms

5. Alcohol Withdrawal Symptoms

6. Treatment of Alcohol Withdrawal

7. Rehab

Making a Diagnosis of Alcohol Use Disorder

• Be suspicious:

  • Accidents and falls

  • Ability to drink more than others

  • Lying to family and co-workers

  • Blackouts

• Abnormal laboratory findings:

  • High blood alcohol concentration

  • Increased MCV, high cholesterol, elevated liver enzymes (GGT acutely)

• Physical findings:

  • Enlarged red nose and reddened palms

  • Enlarged liver and spider veins

  • Gynecomastia and testicular atrophy

---

Medical Complications

• Fatty liver 

  • -> cirrhosis and failure

• GI problems: 

  • gastritis, ulcers, bleeding, diarrhea

• Pancreatitis

• Cardiomyopathy 

  • -> heart failure

• Neuropathy

• Cerebellar damage 

  • -> ataxia

• Wernicke’s encephalopathy/ Wernicke-Korsakoff syndrome

  • acute syndrome

  • cognitive and memory impairment

• Cancers 

• Infections 

  • TB, frequent pneumonias

• Fetal alcohol syndrome

---

Psychiatric and Social Complications

• Alcohol related dementia

• Depression and anxiety

• Suicide

• Intoxication -> accidents, fights and falls

• Withdrawal problems

• Marital and family problems

• Loss of jobs

• Legal problems

• Increased use of other drugs

---

Alcohol Intoxication

• One of more of the following signs

  • Slurred speech

  • Incoordination

  • Unsteady gait

  • Nystagmus

  • Impairment in attention or memory

  • Stupor or coma

---

Alcohol Withdrawal

•  Two (or more) of the following

  • Autonomic hyperactivity

  • hand tremor

  • Insomnia

  • N/V

  • Transient hallucinations 

  • Psychomotor agitation

  • Anxiety

  • Generalized tonic-clonic seizures

  • Delirium

• 6 - 48 hours after cessation or sig decrease in use

---

Treatment of Alcohol Withdrawal

• Use drug similar to Alcohol (GABA binding)

  • BZD’s

    • W/ Liver/Brain Damage: oxazepam or lorazepam + freq. dosing

    • W/O Liver/Brain Damage: chlordiazepoxide or diazepam

  • DAY 1: treat withdrawal symptoms -> decreased 20% each day for next 4 days

• Replace fluids + thiamine + folic acid

• Anticonvulsants -> antiseizure, preserve cog, prevents relapse

  • valproic acid, carbamazepine or gabapentin

---

Rehabilitation

• CBT 

  • modifying thoughts and behaviors regarding drinking

• 12 step programs

  • AA

• Treat underlying psychological illness

• Other:

  • Network, Family, Couples, Inpatient Programs, Therapeutic Communities

What is CIWA

Describe Disulfiram

• Clinical Usage

• AE

• Instruction

• Effects

Disulfiram

• Clinical Usage:

  • managing chronic alcoholics who wish to remain abstinent

• AE:

  • Compliance

    • Medication works best if supervised by a spouse or partner

  • Metallic Taste

  • Sulfur Odor 

  • RARELY:

    • hepatotoxic, psychosis, neuropathy

• Instruction:

  • Dose at 250 mg daily and advise patient not to drink for at least 5 days if stopped

• Effects:

  • Feeling Hot

  • Facial flushing,

  • Pounding headaches, 

  • N/V

Describe Naltrexone

• Class

• MOA

• Genetics

• Clinical Usage

• Side Effects

Naltrexone

• Class:

  • Opioid Antagonists:

• MOA:

  • Alcohol -> affects production/release/activity of opioid peptides 

  • -> Enhances midbrain DA Release (thus alcohol feels good) 

• Genetics:

  • FH+ + Genetic high risk -> exaggerated alcohol-induced rise in Beta- endorphin levels

• Clinical Usage:

  • Motivated pts

  • PTs who describe addiction as a craving

• Side Effects:

  • Nausea, 

  • headache, 

  • anxiety 

  • sedation

• CI:

  • Severe liver damage

  • Pts taking opiods

Describe Acamprosate

• Class

• MOA

• Clinical Usage

• PK

• Benefits

Acamprosate

• Class:

  • NMDA Antagonist or Inhibitory Modulator

• MOA:

  • Excitatory NMDA contributes to alcohol’s intoxicating, cognitive/dependence-forming effects

• Clinical Usage:

  • Decrease withdrawal symptoms

  • Assist in abstinence

• PK:

  • Poorly absorbed, 

  • bioavailability of 11%

  • Excreted via kidneys without metabolism

• Benefits:

  • NO Hepatotoxicity

  • Few AE

    • Diarrhea = MC

Describe Cannabis Use

• Dif between THC and CBD

• AE

• Intox. Effects

• Withdrawal

Dif between THC and CBD

• THC: psychoactive effects

  • analgesic, anti-nausea, appetite-stimulating and ant-spastic effects

• Cannabidiol: not psychoactive

  • anti-inflammatory, anti-anxiety, anti-epileptic and antipsychotic effects

---

AE:

• Cardiovascular

  • Increased risk of 

    • stroke, heart disease and other vascular problems

• Pulmonary

  • Smoking -> damage lung tissue

• Pregnancy

  • stillbirth, 

  • decreased fetal growth, 

  • premature birth,

  •  Long- term infant developmental issues

• Neuro

  • Addiction ~ 30%

• Cognitive impairment

  • Irreversible up to 8 IQ point loss

---

Cannabis intoxication

• behavioral/psychological changes

  • impaired motor coordination, 

  • euphoria, 

  • anxiety,

  • sensation of slowed time, 

  • impaired judgment, 

  • social withdrawal

• Two or more of symptoms w/in 2 hrs:

  • Conjunctival injection

  • Increased appetite

  • Dry mouth

  • Tachycardia

---

Cannabis Withdrawal: 

• Three or more

  • Irritability, anger or aggression, anxiety

  • Sleep difficulty

  • Decreased appetite or weight loss

  • Restlessness

  • Depressed mood

• One of the following -> sig. Discomfort:

  • abdominal pain,

  • shakiness/tremors, 

  • sweating, 

  • fever, chills, 

  • headache

Describe Phencyclidine Use Disorder

• Effects

  • Low

  • High

  • Really High

• Management

• Intox Effects

Effects:

• Low doses (1-5 mg)

  • Numbness, 

  • relaxation, 

  • euphoria, 

  • Slurred speech, 

  • loss or motor coordination, 

  • misperception of strengths or invulnerability

•  High doses ( 6-10 mg or higher)

  • delirium, 

  • hallucinations,

  • delusions of grandeur, 

  • anxiety, 

  • panic, 

  • Increased BP/HR,

  • breathing problems, 

  • raised body temperature, 

  • agitation and violence

• Very high doses (>20 mg)

  • Risky behavior, 

  • coma, 

  • seizures 

  • death from respiratory depression

---

Management:

• Treat intoxication in ICU

  • Safe environment

  • High BP:

    • benzodiazepines, antipsychotics (low anticholinergic), phentolamine 

---

Intox Effects:

• Behavioral or psychological changes

  • belligerence, 

  • assaultiveness, 

  • impulsiveness, 

  • unpredictability,

  • psychomotor agitation, 

  • impaired judgment

• Within one hour, two (or more), w/in two hours of use

  • Vertical or horizontal nystagmus

  • Hypertension or tachycardia

  • Numbness or diminished responsiveness to pain

  • Ataxia

  • Dysarthria

  • Muscle rigidity

  • Seizures or coma

  • Hyperacusis

Describe Hallucinogens

• Types

• MOA

• Intox Effects

  • Behavioral or psychological changes 

  • Perceptual

  • Physical Symptoms

• What is Hallucinogen Persisting Perception Disorder

Types:

• peyote, mescaline, LSD, psilocybin, MDMA (Ecstasy)

  • all Schedule I

MOA:

• Affects DA, Ht, AcH, GABA

---

Intox Effects:

•  behavioral or psychological changes 

  • Anxiety or depression, 

  • ideas of reference, 

  • fear of “losing one’s mind,” 

  • Paranoid ideation, 

  • impaired judgment

• Perceptual changes

  • subjective intensification of perceptions, 

  • depersonalization/derealization,

  • illusions, 

  • hallucinations, 

  • Synthesias

• Physical Symptoms (2)

  • Pupillary dilation

  • Tachycardia

  • Sweating

  • Palpitations blurring of vision

  • Tremors

  • incoordination

---

Hallucinogen Persisting Perception Disorder

• Cessation of hallucinogen -> reexperiencing one or more symptoms that were experienced while on hallucinogens

Describe Inhalents:

• Characteristics

• Dangerous b/c?

• Intox Effects?

Characteristics:

• Psychoactive vapors

• CNS Depressant w/ short period of intox

• Used in younger, males, low-income

---

Dangerous:

• Permanent brain Damage

  • Heavy metals and the hydrocarbons

• Toxic to liver and kidneys

---

Intox Effects:

• behavioral or psychological changes

  • belligerence,

  • assaultiveness, 

  • apathy, 

  • impaired judgment)

• Physiologic Symptoms (2 or more)

  • Dizziness

  • Nystagmus

  • Ataxia

  • Slurred speech

  • Hallucinations/Delusions

  • Unsteady gait

  • Lethargy

  • Depressed reflexes

  • Psychomotor retardation

  • Tremor

  • Generalized muscle weakness

  • Blurred vision or diplopia

  • Stupor or coma

  • Euphoria

Describe Fentanyl

• What is it?

• Clinical Usage

• Added in?

Describe Kratom

• What is it?

• Effects

• MOA

Fentanyl

• What is it?

  • Very potent synthetic opioid

• Clinical Usage:

  • anesthesia + post-op pain

  • Severe cancer pain (when other opioids no longer effective 

    • Transdermal patch

    • Lozenges or lollipops

• Added in:

  • Heroin

  • Amphetamines 

---

Kratom

• What is it?

  • Recreational drug in SE Asia and the West

  • mitragynine and 7-hydroxymitragynine

  • Can be used as self-management of opioid withdrawal

• Effects?

  • Small doses = stimulatory 

  • Larger doses = sedative-narcotic effect

  • Withdrawal = same as opioid withdrawal

• MOA:

  • Bind to 

    • opioid + serotonin + noradrenaline + dopamine receptors 

Describe Opiod Use disorder:

• Medical Complications of Opioid Dependence

• Intox Effects

• Withdrawal Effects

Medical Complications of Opioid Dependence

• Infections (via) injecting

  • Endocarditis

  • Hepatitis B, C and delta

  • Cellulitis and abscesses

  • Aspiration pneumonia

  • Osteomyelitis and septic arthritis

  • HIV and STD’s

• Endocrine, primarily reproductive

  • Decreased sperm motility

  • Menstrual abnormalities and amenorrhea

• Gastrointestinal

  • Constipation

  • Pseudo-obstruction of the bowel

• Liver disease, 

  • primarily from viral infections

• Respiratory depression

• Trauma from accidents, violence, sexual abuse

• Depression and suicide

---

Opioid intoxication

• Behavioral or psychological changes 

  • initial euphoria followed by 

    • apathy, 

    • dysphoria, 

    • Psychomotor agitation or retardation

    • ,impaired judgment

• Physical Symptoms

  • Pupillary constriction (or dilation due to anoxia from severe overdose) + One

    • Drowsiness or coma

    • Slurred speech

    • Impairment in attention or memory

---

Withdrawal Effects (3)

• Dysphoric mood

• N/V

• Muscle aches

• Lacrimation or rhinorrhea

• Pupillary dilation, 

• Piloerection,

• sweating

• Diarrhea

• Yawning

• Fever

• Insomnia

Describe Naloxone in regards to opiods:

• Effect

• Why timing = essential

• MOA

Naloxone

• Effect:

  • Reversal of Overdose:

• Why is Timing = essential 

  • Brain death starts in 4-8 minutes after breathing stopped

• MOA:

  • Pure mu receptor short-acting antagonist

Describe Methadone

• Usage

• Benefits

• MOA

• CI

• Short vs Long term Detox

• Chronic Use Effects

• PK

• Program Usage

Methadone

• Usage:

  • Treatment of Withdrawal

    • Avoids some withdrawal symptoms and provides setting for psychosocial rehabilitation

• Benefits:

  • cross tolerant, orally effective, long-acting cheap

• MOA

  • μ and δ agonist

  • NMDA antagonist

• CI:

  •  For withdrawal from less addictive drugs 

    • propoxyphene or pentazocine

    • Instead: decrease dose or use clonidine 

• Short vs long term detox:

  • Short: 30 days

  • Long: 180 days

• Chronic Use Effects:

  • Proved safe/efficient when monitored

    • No long term damage to organ systems

    • HPA axis and immune function normalize

  • AE:

    • Constipation common

    • orgasmic dysfunction in men

    • QT Widening at high doses

---

PK:

• Rapidly/Completely Absorbed

  • Highly lipophilic + Large Distribution + Accumulation in solid organs

• Timing:

  • Peak plasma levels in 2-6 hours

  • Pain relief lasts about 6 hours

• Metabolism:

  •  Cytochrome P450

---

Program Usage:

• Need policies for illicit use

• Expect relapses and support return to program

• Have counseling components

• Reward clean urines and other positive behaviors

  • privilege of take-home doses

Describe Clonidine:

• Cons

• OTher Comfort Medications

• 
  

Clonidine

• Cons:

  • hypotension, sedation and dizziness

  • Does not work for:

    • irritability, insomnia and muscle aches

• Comfort medications 

  • NSAIDs for muscle cramps or pain,

  • dicyclomine for abdominal cramps, 

  • ondansetron for N/V

Describe Buprenorphine

• MOA

• Benefits

• AE

Buprenorphine

• MOA:

  • Mixed μ receptor agonist / antagonist

    • Effectively blocks effects of opiates and thus the reward qualities

• Benefits:

  • long-acting and safe

  • Pt little cravings or relapses

• AE:

  •  Can precipitate withdrawal reaction if given too soon after use of opioid agonist

---

NOTE:

• Available initially as a parenteral analgesic

• Now in sublingual tablet and rapidly dissolving film for detox and maintenance

• Now two depot injection preparations lasting 30 days which are being used in prisons

• Can be prescribed in doctor’s office or methadone clinic, also now in jails

What is MAT?

• What is it?

• Goals

• Uses

• Cons

Opiate Substitution or Medication Assisted Treatment (MAT)

• What is it?

  • Continual, regular use of Methadone + Buprenorphine

    • Prevents intox/withdrawal periods 

• Goals:

  • reduce or prevent the adverse effects of drug use 

  • improve 

    • functioning, quality of life and overall functioning

• Uses:

  • Should be partnered with rehabilitation services and supportive counseling, individual or group

• Cons:

  • Some social and political opposition

  • Limited availability of clinics or spaces

  • Limited financial resources of many patients

  • Need to attend regularly

  • Not enough trained professionals

Describe Naltrexone

• MOA

• AE

• CI

• Uses

Naltrexone

• MOA:

  • Binds tightly to the μ (mu) receptor

    • Prevents other opioids from binding

    • Pt loses interest/no craving 

• AE:

  • Nausea, 

  • headache, 

  • anxiety 

  • sedation

• CI:

  • severe liver disease

• Uses:

  • Alcohol use Disorder

  • Opioid use disorder

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NOTE:

• Would like to see use increased in those leaving a detox program, jail or prison to decrease risk of relapse

• Many drug court patients have been ordered into Naltrexone treatment

• Depot shot expensive but some insurance including Medicaid covers

Describe Sedative, Hypnotic or Anxiolytic Use Disorder

• Intox Effects

• Withdrawal Effects

• Tx

Intox Effects:

• behavioral or psychological changes

  • inappropriate sexual or aggressive behavior, 

  • mood lability,

  • impaired judgment

• Physical Symptoms (one or more)

  • Slurred speech

  • Incoordination

  • Unsteady gait

  • Nystagmus

  • Impairment in cognition 

    • (i.e., attention, memory)

  • Stupor or coma

---

Withdrawal Effects (two or more):

• Autonomic hyperactivity 

  • (e.g., sweating or pulse rate greater than 100 bpm)

• Hand tremor

• Insomnia

• N/V

• Transient hallucinations/illusions

• Psychomotor agitation

• Anxiety

• Grand mal seizures

---

Treatment

• Medical detoxification:

• Psychotherapy: 

• Support groups

Describe Stimulant Use Disorder

• Intox Effects

• Withdrawal Effects

• Overdose consequences

• Tx

Intox Effects:

• behavioral or psychological changes

  • euphoria 

  • affective blunting, 

  • changes in sociability, 

  • hypervigilance, 

  • Interpersonal sensitivity, 

  • anxiety, 

  • tension or anger, 

  • stereotyped behaviors, 

  • Impaired judgment

• Physical symptoms (two or more)

  • Tachycardia or bradycardia

  • Elevated or lowered BP 

  • Pupillary dilation

  • Perspiration or chills

  • N/V

  • weight loss

  • Psychomotor agitation or retardation

  • Muscular weakness,

  •  respiratory depression, 

  • chest pain 

  • cardiac arrythmias

  • Confusion, 

  • seizures, 

  • dyskinesias, dystonias or coma

---

Withdrawal Effects (two or more):

•  Fatigue

• Vivid unpleasant dreams

• Insomnia or hypersomnia

• Increased appetite

• Psychomotor agitation or retardation

---

Overdose Consequences:

• MI

• CVA

• Seizure

• Sudden death

---

Treatment

• Antipsychotics

  • Is psychotic

• Benzodiazepines or sedating antipsychotics(quetiapine) 

  • irritability of withdrawal

• Antidepressants

  • >2 weeks 

• Operant conditioning: 

• CBT and support groups