Chapter 19 : Addiction Lecture Notes

Alcohol Use Disorder : Overview

* National Health Problem
* Prevalence in the US
* 16.6 million adults (age > 18 years)
* 697,000 adolescents (age 12-17 years)
* 88,000 people die from alcohol related problems EACH YEAR

Detrimental Effects

* THIRD leading preventable cause of death in the United States
* Absenteeism at work
* Prenatal Exposure
* Increased Violence

third

Alcoholism is the ______ leading preventable cause of death in the United States

Prenatal Exposure

* Infants develop fetal alcohol syndrome
* Increasing at an alarming rate
* Infants with fetal alcohol syndrome will have lifelong consequences
* Learning disabilities

Opioid Crisis

* Cause of estimated 130 deaths daily in the United States
* Overdose
* Many people believe the crisis is related to the CARELESS prescriptions of narcotics
* Doctors handing out scripts
* Physicians will hand out inappropriate prescriptions to people who either don’t need them at all or are giving them a medication that is necessary for the current medical diagnosis (a small sports injury and being prescribed Vicodin)
* Use of Heroin and other elicit opioids has also fueled the problem
* Crosses lines of gender, race, age

130 deaths DAILY

How many deaths are due to overdose daily in the United States?

1. Doctors carelessly prescribing prescriptions or giving inappropriate prescriptions and 2. The use of heroin and other elicit opioids

What is the opioid crisis in the United States due to?

AMA Opioid Recognition

AMA recognize that elicit fentanyl, fentanyl analogs, methamphetamines, and cocaine often when combined are DRIVING the epidemic

* Fentanyl - regulation → must have crash cart right next to you
* Can cause respiratory arrest in SECONDS
* Highly POTENT

Fentanyl

* HIGHLY regulated
* Must have a crash cart in the patient’s room or next to their room when a patient is prescribed fentanyl
* Can cause RESPIRATORY ARREST in seconds
* Highly POTENT

Department of Health and Human Services 5-Point Program to Improve (2019)

* Access : Prevention, treatment, recovery services
* Data : Data on the epidemic
* Pain : Pain management
* Overdoses : Targeting of overdose-revering drugs
* Research : Research on pain and addiction

Categories of Drugs

* Alcohol
* Sedatives, Hypnotics, and Anxiolytics
* Stimulants
* Cannabis
* Opioids
* Hallucinogens
* Inhalants

Substance Use Disorders Terminology

* Intoxication
* Withdrawal syndrome
* Detoxification
* Substance abuse
* Substance or chemical dependence
* Substance use

Onset and Clinical Course

* Early course of alcoholism can be seen as early as 8 years old with sipping
* Creates patterns where this person will develop MORE severe difficulties in their mid 20s and 30s
* Can lead to DUI and arrest, and impact relationships
* First intoxication in adolescence
* More severe difficulties in the mid-20s to mid-30s
* Black out
* Tolerance
* Tolerance Break
* Periods of abstinence or temporarily controlled drinking
* Relapse rate of 60-90%
* Highest rates for successful recovery when there is COMPLETE abstinence and a HIGHER level of motivation
* For many, substance use becomes a chronic illness
* Poor outcomes associated with earlier age of onset as well as the coexistence of a major PSYCHIATRIC DISORDER
* Alcoholism + another Psychiatric Disorder = Poorer outcome

8 years old with sipping

What is the earliest onset for alcoholism?

* Black Out
* Tolerance
* Tolerance Break

What are more severe difficulties in the mid-20s to 30s people with alcoholism may have?

60-90%

Relapse rate of alcoholism is what?

a psychiatric disorder

Poor outcomes associated with earlier age of onset as well as the coexistence of a what?

Black Out

* Usually related to alcohol consumption
* Person will continue to function and have no recollection of activity
* Not know what they have done

Tolerance Break

Need for more and more of a substance to produce the same effect

Tolerance

When there is very LITTLE of the substance needed for intoxication

Relapse Rate

60-90%

Related Disorders

* Gambling Disorder
* Caffeine and tobacco addictions
* Substances can induce similar symptoms to those of mental illness diagnoses

Gambling Disorder

Nonsubstance related diagnosis

Caffeine and Tobacco Addictions

Not considered mental health disorders but are considered ADDICTIONS

Substances R/T Mental Illness DX

* Can induce symptoms similar to those of other mental illness diagnoses
* Anxiety, Psychoses, or mood disorders
* Amphetamines can cause substance-induced psychoses
* can become permanent due to damage brain receives

Symptoms Caused By Substances

* Anxiety
* Psychoses
* Mood Disorders

Amphetamines

Which drug-class can cause substance-induced psychoses?

Etiology

* No CLEAR CUT CAUSE identified for addiction disorders
* Most of the research that has been done has focused on alcohol use disorders

Biological Factors

* Genetic Vulnerability
* Neurochemical Influences

Psychological Factors

* Family Dynamics
* Coping Mechanisms

Genetic Vulnerability

* Children of alcoholics are MORE likely to develop alcohol and substance-use disorders
* Increased risk partly due to environmental factors

Neurochemical Influences

* Stimulation of Dopamine pathways
* Dopamine is a pathway in the limbic system, producing that HIGH for the patient
* Internal control that stops that after a couple drinks (depending on body weight and size)

Dopamine

Neurochemical influences start with the stimulation of the _______ pathways

limbic

Dopamine is a pathway in the ______ system, producing a HIGH for a patient

Family Dynamics

* Can also be caused by inconsistent parenting, poor role-modeling, lack of nurturing
* Doesn’t mean it is always related to these things

Coping Mechanism

* Many use it as a coping mechanism to RELIEVE stress
* Will also use it to decrease psychological pain
* In large amounts, ALCOHOL can increase NERVOUSNESS and muscle TENSION

stress, psychological

Many people use alcohol as a coping mechanism to relieve _______ and decrease _______ pain

large

In _______ amounts alcohol can increase NERVOUSNESS and muscle TENSION

Social and Environmental Factors

* Younger people tend to experiment with alcohol and cannabis ; whether real of synthetic
* More acceptable in society
* Older adults tend to use cocaine and opioids which is LESS acceptable and MORE costly
* Most people feel that recreation use of cannabis is NOT harmful
* Several states where cannabis use is NOT illegal for ingestion
* Cultural Factors, Social Attitudes, Peer Behaviors
* Laws, cost, availability

Alcohol and Cannabis

Younger people experiment with what more?

More

Is the use of cannabis and alcohol more or less socially acceptable?

Cultural Considerations

* Attitudes vary in different cultures
* Certain ethnic groups have genetic traits predisposing them to or protecting them against alcoholism
* Variations in genes for enzymes involved in alcohol metabolism among various ethnic groups
* Alcohol abuse : plays a part in the five leading causes of death for Native Americans and Alaska Natives
* Flushing Effect

Cultural Attitudes - Alcohol

* Muslims don’t drink alcohol
* Wine is an integral part of Jewish religious rights
* Some native American tribes use peyote in religious ceremonies
* Hallucinogens

peyote, hallucinogen

Some native American tribes use _______ in religious ceremonies, which is a ________

* Native Americans
* Alaska Natives

Alcohol Abuse : plays a part in the five leading causes of death for which two ethnicities

Flushing Effect

* Reddening of the face and neck as a result of INCREASED blood flow
* Genetic
* Happens when a person drinks alcohol

Alcohol Intoxication and Overdose

* Central nervous system (CNS) depressant ; relaxation/loss of inhibitions

Alcohol Intoxication

* Slurred speech, unsteady gait, lack of coordination, impaired attention, memory, and judgement
* Most people don’t realize they are unsteady or uncoordinated
* Aggressive behavior
* Angry
* Inappropriate sexual behavior

Alcohol Overdose

* Vomit, Unconscious, Respiratory Depression
* Treatment
* Gastric Lavage

Gastric Lavage

* Treatment for alcohol overdose
* Stomach pumping
* Always want to support respiratory and cardiovascular functioning - some of these patients end up in the ICU

Alcohol Withdrawal

* Onset within 4-12 hours after cessation or marked reduction of alcohol intake
* Will usually peak on day 2 and it takes 5 days for it to be complete
* Can be life-threatening
* S/S
* Coarse hand tremors, sweating profusely, elevated pulse and BP, insomnia, anxiety
* Severe or untreated can progress to
* Transient hallucinations, seizures, or delirium
* Needs to be done in a controlled atmosphere due to complications
* Benzodiazepines are used for safe withdrawal

Alcohol Withdrawal Time Period

4-12 hours after cessation or marked reduction or alcohol intake

2, 5 days

Withdrawal will usually peak on day ___ and it takes ___ days for it to be complete

S/S of Withdrawal

* Coarse hand tremors
* Sweating profusely (diaphoresis)
* Elevated pulse (tachycardia)
* Hypertension (hypertension)
* Insomnia
* Anxiety

Severe or untreated withdrawal can progress TO

* Transient hallucinations
* Seizures
* Delirium

Benzodiazepines

What medication is used for safe withdrawal?

Long-Term Complications - Alcoholism

* Cardiac myopathy
* Wernicke encephalopathy
* Korsakoff psychosis
* Pancreatitis
* Esophagitis
* Hepatitis
* Cirrhosis
* Leukopenia
* Thrombocytopenia
* Ascites

Sedatives, Hypnotic, Anxiolytics

* Benzodiazepines and Barbiturate are MOST commonly used

Benzodiazepines and Barbiturates

_________ and _________ are most commonly used

S/S Intoxication - Sedatives, Hypnotic, Anxiolytics

* Going to cause CNS depressant, the intensity depends on the medication they have ingested
* S/S
* Slurred Speech
* Lack of coordination
* Unsteady gait
* Labile mood
* Stupor

lethal

Barbiturate overdose is potentially _________

* Patients can go into coma, respiratory arrest, cardiac arrest, and death

Benzodiazepine - Alprazolam

* Used frequently
* Xanax
* One of the tell-tale signs someone is taking Xanax is these patients tend to have SLURRED speech and movements
* Have not ingested any alcohol

Onset of Withdrawal - Sedatives, Hypnotics, Anxiolytics

* Onset of withdrawal is dependent on half-life of drug
* Symptoms opposite of drug’s ACUTE EFFECT

Detoxification - Sedatives, Hypnotics, Anxiolytivs

* Via drug tapering

Stimulants

* Amphetamines, Cocaine (considered a white-collar drug)
* Work in CNS

Intoxication S/S - Stimulants

* High and euphoric feelings
* Hyperactivity
* Hypervigilance
* Anger
* Elevated BP (Hypertension)
* Chest Pain
* Confusion

Overdose S/S - Stimulants

* Seizures
* Coma

Withdrawal - Stimulants

* Onset within hours to several days
* Lorazepam withdrawal lasts 10 hours
* Symptoms start in 6 hours
* Diazepam withdrawal may not produce symptoms for a week
* Primary Symptom is marked dysphoria FOR WITHDRAWAL
* “Crashing”
* NOT treated pharmacologically

Stimulants Onset of Withdrawal

Hours to several days

Lorazepam Withdrawal

* Lasts 10 hours
* Symptoms start in 6 hours

Diazepam Withdrawal

* May not produce symptoms for a WEEK

Primary Withdrawal Symptom - Stimulants

* Marked dysphoria

Crashing

* As they are coming down from these medications this will happen
* Depressive symptoms occur, including suicidal ideations

Stimulant Withdrawal

* Not treated pharmacologically

Cannabis (Marijuana)

* Used for psychoaffective effects
* Medical applications

Cannabis Intoxication

* Lowered Inhibitions
* Relaxation
* Euphoria
* Increased appetite

Symptoms of Intoxication

* Increased motor control
* Impaired judgment

Withdrawal - Cannabis

* NO clinically significant withdrawal syndrome
* Possible symptoms of muscles aches, sweating, anxiety, tremors
* Withdrawing or stopping marijuana is not something we worry about a lot

Opioids

* Desensitization to pain, euphoria, and well-being

Opioids - Intoxication

* Apathy\*
* Lethargy
* Listlessness
* Impaired judgement
* Psychomotor retardation
* Agitation
* Constricted pupils\*
* Drowsiness\*
* Slurred speech
* Impaired attention\* and memory

euphoric

Administration of 1 opioid will make you tired but someone addicted will ________ and overcome any tiredness (don’t get this feeling)

Opioid Overdose S/S

* Coma
* Respiratory Depression
* Pupil Constriction
* Unconsciousness
* Death

Opioid Overdose Treatment

* Naloxone (Narcan)
* Intranasaly

Opioid Withdrawal

* Onset depends on the type of drugs
* Symptoms are not life-threatening
* Nausea, vomiting, rhinorrhea, sweating, fever, diarrhea, insomnia
* DO NOT require pharmacological intervention

Opioid Withdrawal S/S

* N/V
* Rhinorrhea
* Sweating
* Fever
* Diarrhea
* Insomnia

T/F : Opioid withdrawal DOES NOT require pharmacological intervention

True ; it doesn’t

Heroin

* Short acting opioid

Heroin - Onset

* 6-24 hours after last ingestion

Heroin - Peak

2-3 days

Heroin - Duration

* Subsides from the body in 5-7 days

Examples of Longer-Acting Opioids are…

* Methadone
* Onset 2-4 days
* Symptoms subside in 2 weeks
* Opioid
* Less severe than heroin
* Controlled medication in the healthcare setting
* Oral form\* given

Methadone Onset

* 2-4 days

Methadone Symptoms Subside in…

2 weeks

Hallucinogens

* Types : PCP, Shrooms, Molly, LSD (untestable)
* S/S → reality distortion ; symptoms similar to psychosis including hallucinations (usually visual), depersonalization (don’t recognize yourself)

psychosis

Hallucinogens involve reality distortion with symptoms similar to _______ including :

* Hallucinations (visual)
* Depersonalization

S/S → Hallucinogens

* Increased pulse (Tachycardia)
* Hyperreflexia
* Inc. in Temperature (Hyperthermia)
* Dilated pupils

Hallucinogens Intoxication

* Maladaptive behavior/psychological changes
* Anxiety
* Depression
* Paranoid ideation (think people are talking about them or listening to them)

overdose, toxic

Hallucinogens involve NO ________ ; _______ reactions are PRIMARILY PSYCHOLOGICAL

Phencyclidine (PCP) Toxicity S/S

* Seizures
* Hypertension
* Hyperthermia
* Respiratory Depression
* Bradypnea

Hallucinogens Withdrawal

* Hallucinogens have NO withdrawal S/S
* Some patients will report they have a CRAVING for the drug

Long-Term Hallucinogen Effects

* Flashbacks (of psychotic episodes)
* Things they have encountered while taking these
* These can happen up to 5 years