Substance Use Disorders

what is addiction

a primary, chronic disease of brain reward, motivation, memory related circuitry

-dysfunction in these circuits leads to biological, psych, and social manifestations

what structures of the brain does addiciton affect

-nucleus accumbens

-anterior cingulate cortex

-basal forebrain

-amygdala

what accounts for half of the likelihood that someone will develop addiction

genetic factors

what psych disorders cooccur with addiction

ADHD, anxiety, depressive disorders, personality disorders, bipolar

pathophysiology of reward

-normally dopamine released from ACC to NC when we do things that promote survival

-substances cause more dopamine to be released for a greater duration of time so people are more likely to repeat the behavior since nothing else creates that euphoria

-reward center introduced to new threshold of pleasure

pathophysiology of memory

-addiction affects neurotransmitters and interactions between cortical and hippocampal circuits and nucleus accumbens so that the memory of past rewards leads to biological and behavioral response to external cues-triggers craving/engagement in addictive behaviors

what is the frontal lobe responsible for

-storing negative consequences to avoid poor actions in the future

-inhibiting impulsivity and appropriately delay gratification

-pt w/ addiction have frontal lobe severely underdeveloped

core principles of harm reduction

-focus on reducing harm rater than aiming for abstinence

-non judgmental client centered care

-recognition of the rights of individuals who use substances

SUD DSM criteria

problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least 2:

-taken in larger amount/period than intended

-unsuccessful efforts to cut down on use

-time spent to obtain, use, or recover from effects

-craving

-results in failure to fulfill obligations

-interpersonal problems

-give up social/work activities

-use in situations that are hazardous

-continued use despite knowledge of having a problem

-tolerance or withdrawal

early remission of substance use

no criteria met for at least 3 months but less than 12 (except cravings)

sustained remission of substance use

no criteria met for 12 months (except cravings)

risk factors for alcohol use disorder

-family history

-availability of alcohol

-heavy alcohol use

-binge drinking

-permissive societal attitudes towards alcohol use

-history of childhood abuse

-history of conduct or mood disorder in childhood

-mental health condition like depression or PTSD

-impulsivity

what is considered at risk drinking

-men: >4 drinks/day or >14/wk

-women: >3 drinks/day or >7/wk

-men and women over 65: >3 drinks/day or 7/wk

what amount is considered binge drinking

-men: 5+ drinks in 2-3 hr period

-women: 4+ drinks in 2-3 hr period

screening for alcohol use disorder

-AUDIT (best screening tool)

-CAGE(cut down, annoyed, guilty, eye opener)

-MAST questionnaire

what comorbidities can happen with alcohol use disorder

-gastritis/ulcers/cirrhosis/pancreatitis

-esophageal and stomach cancer

-htn, cardiomyopathy, high triglycerides and LDL

-myopathy

-memory impairment

-degenerative changes in cerebellum

-thiamine def(Wernicke Korsakoff)

lab markers for AUD

-BAC

-GGT-most pts w/ elevated GGT are heavy drinkers

-CDT >20

-MCV

-AST:ALT >2:1

alcohol intoxication

-slurred speech, incoordination, unsteady gait, nystagmus, impairment in memory/attention, stupor/coma

-BAC > 300-400 can inhibit respiration

-body can metabolize 1 drink/hr and BAC should fall 15-20/hr

-significantly increased risk of suicide during alcohol intox

drug screening

-urine(standard), blood, saliva(recent), hair(historical)

-false neg common w/ benzo but not positive

-fentanyl and MAT not on standard test

-checks temp, pH, human DNA markers, matching pharmaceuticals

what substances can be detected in drug screenings

-alcohol

-opioids

-cannabis

-sedative, hypnotic, anxiolytic

-stimulant

-phencyclidine

-hallucinogen

-inhalant

-tobacco

alcohol withdrawal

2+ of the following after cessation of prolonged drinking:

-autonomic hyperactivity(diaphoresis, tachycardia)

-increased hand tremor

-insomnia

-nausea/vomiting

-transient hallucinations

-psychomotor agitation

-anxiety

-generalized tonic clonic seizures (4-6 hrs after last drink)

-can treat short term symptoms w/ low dose benzo

what can happen with severe cases of alcohol withdrawal

-hallucinosis-visual, auditory, tactile hallucinations w/ intact orientation and normal vitals, 12-48 hrs after last drink

-delirium tremens-delirium, agitation, tachycardia, htn, fever, diaphoresis 48-96 hrs after last drink, can be letal

-aggressive tx w/ benzos

wernicke encephalopathy

-thiamine (B1) deficiency

-encephalopathy, oculomotor dysfunction, gait ataxia

-atrophy of mamillary bodies

korsakoff syndrome

-chronic neuro condition as a result of WE

-disorder of selective antegrade and retrograde amnesia (d/t lesions in anterior thalamus), apathy, intact sensorium, and relative preservation of long term memory and other cognitive skills

WE tx

-immediately give IV thiamine (administer before glucose)

what drugs can be used for alcohol use disorder

-Acamprosate(Campral)-helps w/ craving and sobriety management

-Disulfiram (Antabuse)- best for those motivated for sobriety

-Naltrexone helps w/ cravings and heavy drinking

Acamprosate (Campral)

-start lower if renal impairment, avoid if severe

-glutamate neurotransmission modulation at metabotropic 5 glutamate receptor

-reduces cravings and desire to drink

-SE: diarrhea, nervousness, fatigue

-can take w/ naltrexone and disulfiram and in pts who continue to drink

-Contra: CrCl<30

Disulfiram(Antabuse)

-causes unpleasant physiologic reaction when alcohol consumed

-inhibits aldehyde dehydrogenase and prevents metabolism of alcohol's primary metabolite-acetaldehyde

-if alcohol consumed-sweating, HA, dyspnea, low BP, flushing, sympathetic overactivity, palpitations, N/V

-SE: rash, drowsiness, HA, metallic taste, hepatitis

-contra: myocardial disease, coronary occlusion, psychosis, hypersensitivity, pregnancy/breastfeeding

Naltrexone

-mu opioid receptor blocker

-requires monitoring of LFT q 6 months

-reduces dopamine surge assoc w/ drinking

-also modifies hypothalamic pituitary adrenal axis to suppress ethanol consumption

-contra:acute hepatitis and liver failure

risk factors for opioid use disorder

-access/availability

-previous exposure to substance use

-current or past substance use disorder

-family history of substance use disorder

-mental health condition

-history of abuse during childhood

-history of conduct disorder as a child or adolescent

signs of opioid intoxication

-euphoria

-sedation

-slurred speech

-constipation

-analgesia

-decreased respirs

-attentional deficits

-pinpoint pupils/miosis

signs of opioid withdrawal

-dysphoria, anxiety

-insomnia

-diarrhea, nausea, vomiting

-muscle and joint pain

-diaphoresis

-mydriasis

-chills

-piloererction

-tearing

-yawning

primary treatments for opioid withdrawal

-buprenorphine

-methadone

-clonidine

adjunctive tx for opioid withdrawal

-NSAID for pain

-kaopectate or immodium for diarrhea

-hydroxyzine for anxiety or insomnia

-benzos

-decongestants for rhinorrhea

-phenergan for nausea and vomiting

-avoid using needles

COWS rating scale

clinical opiate withdrawal scale

-determines severity and if initiating buprenorphine is appropriate (prefer score at least 10)

benefits of medication assisted treatment

-reduction in mortality

-reduction in illicit opioid use

-retention in treatment programs

-reduced criminal activity

-improved social functioning

opioid agonists

-Buprenorphine (partial)- suboxone, subutex, benavail, zubsolv, sublocade/brixadi SQ

-methadone (full)

-used for detox/withdrawal maintenance

opioid antagonists

naltrexone

-used for long term maintenance

Methadone

-pure agonist, greater OD risk than buprenorphine

-1st line for pregnant pt w/ OUD

-prevents cravings, prevents withdrawal symptoms for 24+ hrs, reduces euphoric effects of opioid use by maintaining high levels of tolerance

-can be used IP for acute withdrawal

Buprenorphine

-opioid partial agonist-some pain relief

-oral combined w/ naloxone to decreased diversion to injection

-pt should have withdrawal symptoms before staring

-safe in pregnancy, but not 1st line

-higher risk of death if also using benzo, alcohol, IV opiates

-does not show up on standard drug screen

-contra-severe hepatic impairment

naltrexone

-opioid antagonist

-oral daily or long acting injection

-must be opioid free or will enter precipitated withdrawal

-can be started 3-6 d after last use of short acting opioids, 7-10 d if long acting

-SE: nausea, HA, dizziness, fatigue, liver damage

-high risk of OD if relapse

-discontinue if pregnant

-contra acute hepatitis and liver failure

emergency pain management and naltrexone

-consider alternative to opioid therapy like regional anesthesia

surgery considerations with naltrexone use

-discontinue naltrexone at least 72 hrs before scheduled elective surgery if opioid use is anticipated

-extended release IM naltrexone should be stopped at least 30 days before surgery

Naloxone (Narcan)

-opioid antagonist that blocks effects of opioid analgesics that reverses the effects of overdose

-no abuse potential

-decreased mortality, does not cause opioid dose escalation

medicinal uses for cannabis

-decrease opioid use

-epilepsy, MS, migraines

-chemo induced nausea/vomiting

-may induce apoptosis and inhibit tumor growth

-appetite stimulation

-mental health-PTSD reduction

-glaucoma

-IBS

-sickle cell

cannabis effects

-impairs attention, concentration, episodic memory, associative learning, motor coordination(dose dependent)

-often use other psychoactive substances

-chronic use-periodontal disease, hyperemesis, low sperm count, small increase risk MI and stroke

-higher rate bronchitis if smoking

-cannabinoid hyperemesis syndrome

-later development of schizophrenia in adolescence

cannabis intox

-conjunctival injection

-increased appetite

-dry mouth

-tachycardia

-specifier-with perceptual disturbances

-effects can last up to 24 hrs before most cannabinoids are fat soluble

cannabis withdrawal

-irritability, anger, aggression

-anxiety

-sleep difficulty

-decreased appetite or weight loss

-restlessness

-depressed mood

-abd pain, tremor, sweating, deveres, chills, headache

signs of meth use

-weight loss

-skin sores

-meth mites

-dental decay

-CV problems

-depression

-psychosis

signs of stimulate intox

-tachy or bradycardia

-mydriasis

-perspiration, chills

-N/V

-weight loss

-agitation or retardation

-muscle weakness, respiratory depression, chest pain, arrhythmias

-confusion, seizures, dyskinesias, dystonias, coma

signs of stimulant withdrawal

-dysphoric mood-always present and required for diagnosis

-fatigue

-vivid, unpleasant dreams

-insomnia or hypersomnia

-increased appetite

-psychomotor retardation or agitation

signs of SHA intox

-slurred speech

-incoordination

-unsteady gait

-nystagmus

-impairment in attention/memory-anterograde amnesia

-stupor or coma

signs of SHA withdrawal

-autonomic hyperactivity-diaphoresis, tachycardia

-hand tremor

-insomnia

-N/V

-transient visual/tactile/auditory hallucinations

-psychomotor agitation

-anxiety

-grand mal seizures

-specifier-with perceptual disturbances

signs of phencyclidine intox

-nystagmus

-HTN or tachycardia

-numbness or diminished response to pain

-ataxia

-dysarthria

-muscle rigidity

-seizures or coma

-hyperacusis

-chronic can lead to deficits in memory, speech cognition that can last for months

-toxicity can cause intracranial hemorrhage, rhabdo, cardiac arrest

hallucinogen intox

-perceptual changes occurring in state of full wakefulness and alertness-depolarization, derealization, illusion, hallucinations

-mydriasis

-tachycardia

-diaphoresis

-palpitations

-blurring of vision

-tremors

-incoordination

-no withdrawal

hallucinogen persisting perception disorder

-following cessation of use, reexperiencing of perceptual symptoms of intoxication

-geometric hallucination, false perception of movement in periphery, flash of color, trails of image of moving objects, macropsia

-visual disturbances are predominant

-primarily after LSD use

-not correlated with number of uses

inhalant intox

-dizziness, nystagmus

-incoordination, slurred speech, unsteady gait, lethargy

-depressed reflexes, psychomotor retardation, tremor

-generalized muscle weakness, blurred vision, stupor, coma, euphoria

-sudden sniffing death-cardiac arrhythmias

-no withdrawal

tobacco withdrawal

-irritability, frustration, anger

-anxiety, difficulty concentrating

-increased appetite, restlessness, depressed mood, insomnia

-peaks 2-3 days after abstinence and lasts 2-3 wks

Chantix/Varenicline

-reduces tobacco craving and withdrawal symptoms

-causes nightmares

nicotine replacement

-patch, gum, lozenge, spray, inhaler

-can also use buproprion/wellbutrin/zyban