Sleep Wake Disorders/Substance Use Disorder

What is insomnia?

- a predominant complaint of dissatisfaction with sleep quality or quality

- the sleep disturbance causes clinically significant distress or impairment in social occupational educational academic behavioral or other important areas of functioning

- the sleep difficulty occurs at least three nights per week

- the sleep difficulty is present for at least three months

- the sleep difficulty occurs despite adequate opportunities for sleep

What is the treatment of insomnia in a clinic?

- start with sleep diary or sleep log

- education to patient about sleep hygiene (goal is 7 hours a night)

- consider melatonin or supplements

- consider trazodone

What are common medications used for insomnia?

- zolpidem (short)

- zaleplon (short)

- ramelteon (short)

- eszopiclone (intermediate)

What increases the effects of zolpidem?

- alcohol

- SSRIs

What medication for insomnia is a melatonin receptor agonist (no GABA activity)?

ramelteon

What are the SE of ramelteon?

- HA

- galactorrhea

What is the gold standard treatment for insomnia?

cognitive behavioral therapy

What is the physiology of addiction?

- dopamine (“feel good” neurotransmitter with regards to addiction & immediate effects)

- serotonin (“mood stabilizer” & contributor to feelings of well-being & happiness)

- gamma-aminobutyric acid (Inhibitory amino acid that ↓ anxiety, ↑ calmness/sedation)

What is hazardous or at risk use?

patterns of substance use that do NOT meet diagnostic criteria for SUD but still put the patient at risk for adverse health consequences

What is misuse or abuse?

- maladaptive pattern of substance use that leads to impairment of occupational, physical, or social functioning or causes distress

- mild-moderate substance use disorder (SUD)

What is tolerance?

need for increased amounts of the substance to achieve the same positive physical or psychological effects

What is cross-tolerance?

development of tolerance to one substance because of use of another substance

What is withdrawal?

- development of acute & potentially dangerous negative physical or psychological symptoms after the reduction or cessation of intake of a substance

- implies physical dependence almost 100% of the time

What is dependence?

- maladaptive pattern of substance misuse or abuse that is more pervasive & persistent, & often includes the development of tolerance as well as withdrawal symptoms, leading to a pattern of compulsive use

- Severe substance abuse disorder (SUD)

What is mentally-ill chemical addicted (MICA)?

- dual diagnosis patients

- patients who carry a diagnosis of both a mental health condition & a substance use disorder

- need a combined approach to therapy

What is intoxication?

exhilaration, excitement, euphoria, or stupefaction caused by a chemical substance

What is detoxification?

- process by which the body clears itself of drugs

- treatment during this stage is designed to manage withdrawal symptoms

- this treatment does NOT address the psychological, social & behavioral problems associated with addiction & therefore does NOT typically produce lasting behavioral changes necessary for recovery

What is substance use disorder?

recurrent use of alcohol and/or drugs causing clinically & functionally significant impairment, such as health problems, disability, and/or failure to meet major responsibilities at work, school, or home

What are the four primary categories of behavior for SUD?

1. Risky use

2. Impaired control

3. Social problems

4. Physical dependence

What are the 11 criteria for SUD?

1. Taking the substance in larger amounts or for longer than you're meant to (in the case of Rx medications)

2. Wanting to cut down or stop using the substance but not able to do so

3. Spending a lot of time getting, using, or recovering from use of the substance

4. Cravings and urges to use the substance

5. Not managing to do what you should at work, home, or school because of substance use

6. Continuing to use, even when it causes problems in relationships

7. Giving up important social, occupational, or recreational activities because of substance use

8. Using substances again and again, even when it puts you in danger

9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance

10. Needing more of the substance to get the effect you want (tolerance)

11. Development of withdrawal symptoms, which can be relieved by taking more of the substance

How do you specify SUD?

- Mild presence of 2-3 symptoms

- Moderate presence of 4-6 symptoms

- Severe presence of 6 or more symptoms

What is early remission and sustained remission for SUD?

- early remission: none of the criteria met for three months

- sustained remission: none of the criteria met for 12 months

What is the criteria for alcohol intoxication?

- Recent ingestion of alcohol

- Clinically significant problematic behavior or psychological changes that develop during, or shortly after, alcohol ingestion

- One or more of the following signs or symptoms developing during, or shortly after, alcohol use: slurred speech, incoordination, unsteady gait, nystagmus, impairment of attention or memory, and stupor or coma

What is the criteria for alcohol withdrawal?

- cessation of alcohol that has been heavy and prolonged

- two or more of the following: autonomic hyperactivity (sweating or pulse greater than 100), increased hand tremor, insomnia, nausea or vomiting, transient hallucinations, psychomotor agitation, anxiety, or generalized tonic-clonic seizures

What are the classifications of alcohol use?

- moderate drinking

- binge drinking

- heavy drinking

What is considered moderate drinking?

- male: 2 drinks/day (14 drinks/week) or 4/occasion

- females: 1 drink/day (7 drinks/week) or 3/occasion

- anything above this is "at risk" or hazardous

What is considered binge drinking?

4 (F)/5 (M) drinks on the same occasion (or over 2-3 hours) on at least 1 day in the past 30 days

What is consdiered heavy drinking?

4 (F)/5 (M) drinks on the same occasion on each of 5 or more days in the past 30 days

What is NIAAA screening?

- One question is used to screen for drinking frequency beyond “moderate” intake

- How many times in the past year have you had: 5 or more drinks in one day OR 4 or more drinks in one day

- If answer is yes --> investigate further with CAGE vs AUDIT

What are the CAGE questions?

- useful strategy to determine if a patient has a more significant problem with alcohol

- Do you eve try to CUT down on your drinking?

- Do you ever get ANGRY or ANNOYED when someone comments on or criticizes your drinking?

- Do you ever feel GUILTY about your drinking?

- Do you ever take a drink the first thing in the morning as an EYE-OPENER to steady your nerves or get rid of a hangover?

- positive if yes to any 2 OR the last item

What os AUDIT?

- Alcohol Use Disorders Identification Test

- 10-item instrument developed by the WHO that can be utilized to: gather greater information about alcohol use patterns, screen for alcohol-related problems, and quantify severity of alcohol use disorder

- > 15 = alcohol dependance

What are barbiturates used for, and what do they have potential for?

- used medically as sleeping pills, sedatives, tranquilizers, anticonvulsants, & anesthetics

- high potential for misuse & low safety margin

What are benzodiazepines used for?

- used MORE COMMONLY medically as sleeping pills, sedatives, tranquilizers, anticonvulsants, & anesthetics

- relatively high* safety margin unless taken with another CNS depressant

What are the principles of motivational interviewing?

- Express empathy: Understand and acknowledge the client's perspective and feelings.

- Develop discrepancy: Help the client see the gap between their current behavior and their goals.

- Roll with resistance: Avoid directly confronting resistance, instead, explore it and help the client find their own reasons for change.

- Support self-efficacy: Build confidence in the client's ability to make positive changes

What is common with alcohol withdrawal?

alcohol withdrawal delirium (delirium tremens)

What happens in alcohol withdrawal delirium?

- hallucinations (predominately visual)

- disorientation

- tachycardia

- hypertension

- low-grade fever

- agitation

- diaphoresis

- lasts 48 to 72 hours

What is delirium tremens?

- delirium/psychosis observed on the 3rd day of withdrawal in patients with >5 years heavy use of alcohol or benzos

- can involve seizures/cardiovascular collapse

- life-threatening

What are the effects of chronic alcohol use?

- Rosacea, testicular atrophy, or gynecomastia

- Gastritis/PUD

- Pancreatitis

- Liver disease

- Wernicke-Korsakoff syndrome

What does Wernicke-Korsakoff syndrome result from?

thiamine deficiency (vitamin B1)

What is the antidote for benzo overdose/used in detox?

Flumazenil

What are longer-acting benzos/barbiturates used for in SUD?

- replace substance of abuse & taper/wean gradually until abstinent while avoiding withdrawal symptoms

- seizure management & prevention during detox

What are the medications for alcohol use disorder?

- Naltrexone

- Acamprosate

- Disulfiram

- Topiramate

- Gapapentin

How does naltrexone work for alcohol use disorder?

- blunts any positive or "pleasurable" effects of alcohol

- patient has decreased desire/urge to be intoxicated & reduce alcohol cravings

- patients gradually drink less every day thus weaning off alcohol with no withdrawal symptoms

What is the caveat for naltrexone?

must be off opioids 7-10 days before use

How does acamprosate work for alcohol use disorder?

decreases alcohol cravings and urges to drink, but used only after detoxification & abstinence is achieved

How does disulfiram work for alcohol use disorder?

- blocks breakdown of alcohol in the liver resulting in accumulation of acetaldehyde

- ingestion of alcohol while on medication results in intense nausea/vomiting, headache & flushing

How are topiramate and gabapentin used for alcohol use disorder?

- shown efficacy in reducing cravings and preventing relapse

- not yet FDA approved for this indication (off-label use)