Substance-related and addictive disorders

Addiction

A chronic medical condition with roots in the environment, neurotransmission, genetics, and life experiences.

APA definition of SUD

A pathological use of a substance that leads to a disorder of use.

Symptoms of SUD

Impaired control, social impairment, risky use, physical effects (intoxication, tolerance, withdrawal)

DSM-5 TR diagnostic criteria

Alcohol, caffeine, cannabis, hallucinogen, inhalant, opioid, sedative, hypnotic, antianxiety, stimulant, tobacco

Intoxication

When people use a substance to excess

Tolerance

When a person no longer responds to a drug the way that they initially responded; need to take a higher dose to achieve the same initial response.

Withdrawal

A set of physiological symptoms that occur when a person stops using a substance; specific to the substance being used; mild to life threatening.

Schedule 1 drugs

High potential fo rabuse and have no acceptable medical use (heroin and LSD)

Schedule 2 drugs

High potential for abuse, are considered dangerous, and are only available by prescription (methadone, meperidine, and methylphenidate)

Schedule 3 drugs

Low to moderate potential for misuse and are only available by prescription (testosterone, acetaminophen/codeine, buprenorphine.

Schedule 4 drugs

Low-risk drugs and are available by prescription (Xanax, Ativan)

Schedule 5 drugs

Limited quantities of certain narcotics for the treatment of diarrhea, coughing, and pain (guaifenesin and ropitussin, pregabalin, available OTC.

Pathways in addiction

Pleasure and reward pathways that create a memory which contributes to a desire for repeated use.

Overactivation causes the brain to lower levels of…

Neurotransmitters

Biological risk factors for addiction

Genetic vulnerability to addiction, abnormal opioid function (too little natural activity or too much opioid antagonism)

Environmental risk factors for addiction

Poverty, lack of parental supervision, poor educational systems, disadvantaged neighborhoods, lack of support, ineffective coping mechanisms, peer pressure.

Comorbidities for addiction

Depression & anxiety, bipolar disorder, social disorders, other SUD’s, gender dysphoria, gambling (OCD’s)

Stimulants

Cocaine, methamphetamine

Cannaboids

Marijuana, cannabis

Depressants

Alcohol, benzodiazepines

Opioids

Heroin, oxycodone

Hallucinogens

LSD, psilocybin

Inhalants

Glue, paint, gasoline

Hashish

Concentrated form of the cannabis plant

Delta-9

mind altering chemical of the cannabis plant

Synthetic forms of cannabis

Prescribed to prevent nausea and to boost appetite as for some forms of epilepsy

THC

responsible for mind-altering effects in cannabis

Intoxication with cannabis

Conjunctival injection, increased appetite, dry mouth, tachycardia, paranoia, hallucinations and delusions can occur

Withdrawal from cannabis

Occurs within one week of last use. Symptoms include sad mood, irritability, anger, aggression, anxiety, restlessness, insomnia, abdominal pain, sweating, headache, fever.

Treatment for cannabis

Short-term antianxiety meds, therapy, treat underlying depression and anxiety.

Intoxication with sedatives

Slurred speech, incoordination, unsteady gait, nystagmus, impaired thinking, mood fluctuation, impaired judgement, coma

Overdose treatment for sedatives

Gastric lavage, activated charcoal, possible intubation

Withdrawal from sedatives

rebound hyperactivity, tremors, anxiety, insomnia, seizures, onset depends on the half-life of the substance used

Treatment for sedatives

Slow taper, risk of seizures if stopped suddenly or tapered too quickly.

Opioids

Use generally begins in late teens to early twenties. Use causes significant impairment in life.

Opioid intoxication

Drowsiness, slurred speech, alteration in mood and attention, miosis (pinpoint pupils), decreased BP, and RR.

Overdose with opioids

Slow respiration, unresponsiveness, bradycardia, hypotension, coma, pinpoint pupils, extremely dangerous is overdose

Treatment for overdose of opioids

Narcan, short acting so may need a second dose

Opioid withdrawal

Nausea, vomiting, diarrhea, muscle aches, fever, lacrimation, rhinorrhea, dilated pupils, yawning, piloerection, insomnia, and low mood, very uncomfortable but rarely dangerous.

Treatment for opioid addiction

Methadone, buprenorphine, buprenorphine with naloxone, clonidine, therapy, support groups, NA, residential treatment.

Stimulants— Amphetamine, Cocaine

Typically produce euphoria and increased energy. Increase dopamine and norepinephrine in the CNS. Affects the sympathetic nervous system which causes the increase in vital signs.

Intoxication of stimulants

Anxiety, anger, feeling superhuman, physical symptoms can include chest pain, elevated HR, BP, and temperature, arrhythmias, dilated pupils, nausea, vomiting, weakness, seizures, coma.

Stimulant withdrawal

Tiredness, insomnia, or hypersomnia, psychomotor agitation or retardation, depression, paranoia, SI rarely life threatening

Stimulant treatment

Inpatient treatment may be needed to manage intense cravings, therapy, manage symptoms

Tobacco use disorder

Dependence happens quickly. Cravings, persistent and recurring use and tolerance are all symptoms.

Tobacco use disorder withdrawal

At least 4 of the following occur: irritability, anxiety, depression, difficulty concentrating, restlessness, and insomnia.

Tobacco use disorder withdrawal treatment

CBT, hypnosis, NRT (nicotine replacement therapy), which comes in gums, lozenges, nasal sprays, inhalers, and patches; 2 drugs with FDA approval: bupropion and Varenicline are used to reduce cravings and withdrawal. Chantix also blocks nicotine receptors to blunt the effect of nicotine is smoking is resumed.

Gambling disorder

Compulsive activity. Causes economic, social, occupational disturbances. Preoccupied with the behavior. More prevalent in males although progression more rapid in females. Develops over years and may be regular or episodic and possibly interspersed with abstinence.

Treatment for gambling disorder

Through programs such as gamblers anonymous, CBT, individual, group, and family therapy may be needed.

Medications for gambling disorder

Medications include SSRI’s (bupropion, mood stabilizers, and anticonvulsants have been useful. Naltrexone may be given for the most sever symptoms.

Alcohol use disorder

One of the leading causes of substance-related death in the United States. Often co-morbid with other psychiatric disorders— Bipolar disorder, Schizophrenia, MDD.

Alcohol use disorder environmental factors

Peer pressure, low parental supervision leading to early use, cultural acceptance of use

Binge drinking

Drinking too much too quickly

Heavy drinking

Drinking too much too often

Alcohol intoxication

Legal definition is 0.08-010 g/dL. Based on how quickly it is consumed.

0.02 g/dL drink equivalent

2 alcoholic drinks, slower motor performance, decreased thinking ability, altered mood, reduced ability to multitask.

0.05 g/dL drink equivalent

3 alcoholic drinks, impaired judgment, exaggerated behavior, euphoria, lower alertness.

0.08 g/dL drink equivalent

Four alcoholic drinks, poor muscle coordination, altered speech and hearing, difficulty detecting danger, impaired judgment, poor self-control, decreased reasoning.

0.10 g/dL drink equivalent

Five alcoholic drinks, slurred speech, poor coordination, slowed thinking.

0.15 g/dL

Six alcoholic drinks, vomiting (unless high tolerance), major loss of balance

0.20 g/dL

8-10 alcoholic drinks, memory blackouts, nausea, vomiting

0.30 g/dL drink equivalent

More than 10 alcoholic drinks, reduction of body temperature, BP, RR, sleepiness and amnesia.

0.40 g/dL equivalence

Impaired vital signs and possible death

Alcohol withdrawal

Begins 6-8 hours after cessation, must ask when they last had a drink.

Alcohol withdrawal symptoms

Agitation, pacing, nausea, vomiting, insomnia, sweating, increased BP, HR, temperature.

Alcohol withdrawal progression

Perceptual disturbances, psychotic symptoms—> considered a medical emergency. Can lead to seizures; generalized and tonic-clonic — give diazepam IV for withdrawal seizures.

Delirium Tremens (DT’s)

Within the first 72 hours of alcohol withdrawal. Leads to death in 20% of untreated patients, visual and tactile hallucinations are common. Treatment involves benzodiazepine medications such as Ativan and Librium.

Cognitive disturbances related to AUD

Wernicke’s encepalopathy. Memory reducing problem, acute and reversible, thiamine deficiency, confusion, altered gait, vestibulat dysfunction and ocular motility abnormalities. Anisocoria, responds to large doses of IV thiamine for 1-2 weeks. may progress into Korsakoff’s syndrome.

Korsakoff’s syndrome

Chronic condition with only a 20% recovery rate. Related to thiamine deficiency from malabsorption of nutrients. Treat with thiamine for 3-12 months, most patients do not fully recover. However, cognitive improvement may occur.

Blackouts

Caused by excessive consumption of alcohol followed by amnesia. A person actively engages in behaviors that can appear normal. Occurs becuase of alcohol’s ability to block the consolidation of new memories into memories through the hippocampus and related temporal lobe structures.

Fetal alcohol syndrome

Common cause of intellectual disability in the US. Alcohol inhibits intrauterine growth. Microcephaly, craniofacial malformations, and limb and heart defects; short stature as adults.

Systemic effects of alcohol

Peripheral neuropathy, alcoholic myopathy, alcoholic cardiomyopathy, esophagitis, gastritis, pancreatitis, alcoholic hepatitis, cirrhosis of the liver, leukopenia, thrombocytopenia, cancer.

Screening for alcohol use disorder

SBIRT, AUDIT, CAGE, CAGE-AID

SBIRT

Screening, brief intervention, and referral to treatment program; 3 major components.

AUDIT

Alcohol Use Disorders Identification Test

CAGE

4 questions rt alcohol; need to cut down, people annoyed by your drinking, guilty about drinking, and drink in the morning or eye-opener

CAGE-AID

Adds adapted CAGE to include drugs

Treatment for AUD

Biological treatments, pharmacotherapy.

Disulfiram (Antabuse)

First FDA approved medication for AUD

How long does Disulfiram stay in the system for?

2 weeks

Benzodiazepines used for AUD withdrawal

Lorazepam (Ativan), Chlordiazepoxide (Librium), Diazepam (Valium).

Assessment for benzodiazepines

Assess for seizures— Could lead to DT’s

Anticonvulsants/Barbiturates for AUD

Tegretol (carbamezapine), phenobarbital (Luminal). Prescribed for seizures/prevention.

AUD and OUD Treatment

Naltrexone (Revia, Vivitrol) Used to treat dependence. Helps with cravings and reduces pleasure in the activity.

Treatment for OUD

Methadone— reduces craving and withdrawal, blocks the high from opiods. Can help stabilize an individual while they are working on their addiction. Can be used during pregnancy and breastfeeding. Client cannot drink alcohol.

Psychological treatment modalities

CBT— performed by APRNs, substance use and addiction specialists. Helps patients explore thinking patterns so that the core belief system and any irrational core beliefs can be identified.

Motivational interviewing

Based on transtheoretical or stages of change theory.

Pre-contemplation

Admitting there’s a problem

Contemplation

Even after admitting it, they may still not be ready to progress

Preparation

Getting ready and starting the change process

Maintenance

Ongoing commitment, otherwise, relapse.

Care continuum for SUD

Detoxification, rehabilitation, halfway houses, other housing, partial hospitalization program, intensive outpation programs, outpatient treatment, various anonymous programs, relapse prevention.