addictive disorders

Addictive Disorders

Definition of Substance Use Disorders

  • Pathological Use of a Substance: Refers to usage that leads to disorder of use.
    • Symptom Groups:
    • Impaired control over substance use.
    • Social impairment caused by use.
    • Risky use of substances.
    • Physical effects including intoxication, tolerance, and withdrawal symptoms.

Substances Leading to Use Disorders

  • Common Substances:
    • Alcohol
    • Caffeine
    • Cannabis
    • Hallucinogens
    • Inhalants
    • Opioids
    • Sedative-hypnotics
    • Stimulants
    • Tobacco
    • Other Process Addictions:
    • Gambling
    • Shopping
    • Sex

Central Concepts of Addictive Use Disorders

  • Addiction:
    • Described as a chronic medical condition.
  • Intoxication:
    • Engaging in excess use of a substance.
  • Tolerance:
    • Need for higher doses to achieve initial response level.
  • Withdrawal:
    • Symptoms that arise when substance use is stopped.

Clinical Picture of Substances

  • Caffeine:

    • Most widely used psychoactive substance globally.
    • Can result in:
    • Intoxication
    • Overdose
    • Withdrawal symptoms.

  • Cannabis (Marijuana):

    • Third most commonly used psychoactive drug in the US after alcohol and illicit drugs.

  • Hallucinogens:

    • Cause profound disturbances in reality.

  • Inhalants:

    • Includes solvents for glues and adhesives, propellants, thinners, and fuels.

Opioid Use Disorder

  • Common Drugs: Heroin and prescription opiates.
  • Opioid Intoxication Symptoms:
    • Strong cravings leading to increased doses, longer usage.
    • Tolerance increases, resulting in significant impairment in:
    • Life roles
    • Interpersonal relationships
    • Risk of physical hazards.
  • Opioid Overdose:
    • Typically leads to death by respiratory arrest.
    • Treatment for Overdose: Promote breathing; use naloxone.
  • Opioid Withdrawal:
    • Treatments include:
    • Methadone
    • Clonidine
    • Buprenorphine/naloxone
    • Lofexidine (central alpha 2 blocker): decreases norepinephrine release.
  • Opioid Maintenance:
    • Involves pharmacological and psychotherapeutic interventions.

Sedative, Hypnotic, and Antianxiety Medication Use Disorder

  • Problematic Substances Include:
    • Benzodiazepines
    • Benzodiazepine-like drugs
    • Carbamates
    • Barbiturates
    • Barbiturate-like hypnotics.
  • Management Protocols:
    • Overdose treatment via gastric lavage.
    • Withdrawal must involve a gradual reduction to prevent seizures.

Stimulant Use Disorder

  • Clinical Picture:
    • Involves stimulant drugs such as amphetamines and cocaine.
    • Usage Status: Second only to cannabis among illicit substances in the US.
  • Withdrawal Treatment:
    • Involves group and individual therapy.
    • Possible use of diazepam for agitation.
    • Cocaine withdrawal therapy (1-2 weeks) may not require inpatient care; no pharmacological aid to alleviate symptoms.
    • Treatment for subsequent depression may involve medications like bupropion.

Other Disorders Related to Substance Use

  • Tobacco Use Disorder:

    • Withdrawal symptoms are distressing.
    • Treatment options include behavioral therapy, hypnosis, nicotine replacement therapies, and medications like bupropion or varenicline (Chantix).

  • Gambling Disorder:

    • Supported by Gamblers Anonymous (GA).
    • Treatments may include SSRIs, bupropion, mood stabilizers, and anticonvulsants.

Alcohol Use Disorder

  • Definition:
    • Alcohol Withdrawal Syndrome (AWS) is observed in patients with alcohol dependence when alcohol intake is reduced or ceased.
    • Symptoms emerge when blood ethanol levels drop below the habituation threshold, potentially leading to delirium tremens (DT).
    • Onset of Syndrome: 4 to 12 hours after the last drink.
    • Complications: Can lead to severe health issues including death.

Clinical Presentation of AWS

  • Case Study:
    • A 45-year-old male patient exhibits symptoms of restlessness, tremors, tachycardia (HR at 121 bpm), hypertension (BP at 169/104 mmHg), and nausea after heavy drinking cessation for 5 hours.

Alcohol Content Reference Table

  • Comparative Alcohol Content of Common Beverages:
    • Wine:
    • Usual Serving: 1 glass (150 mL, 5 oz)
    • Alcohol Concentration: 12%
    • Alcohol per Serving: 18 mL (0.6 oz).
    • Beer:
    • Usual Serving: 1 can or bottle (360 mL, 12 oz)
    • Alcohol Concentration: 5%
    • Alcohol per Serving: 18 mL (0.6 oz).
    • Whiskey:
    • Usual Serving: 1 shot (45 mL, 1.5 oz)
    • Alcohol Concentration: 40%
    • Alcohol per Serving: 18 mL (0.6 oz).

Alcohol Guidelines

  • Drinking in Moderation:
    • Limit: 2 drinks or less per day for men, and 1 drink or less per day for women.
  • Binge Drinking:
    • Defined as consuming 5 or more drinks for men, and 4 or more drinks for women in one occasion.

Key Highlights of Alcohol Withdrawal

  • Causes: Caused by an abrupt cessation in drinking for patients with dependence.
  • Clinical Presentation from Mild to Severe AWS:
    • Mild Symptoms:
    • Increased heart rate, hypertension, irritability, insomnia, and fine tremors.
    • Moderate AWS:
    • Coarse tremors, agitation in addition to mild symptoms.
    • Severe AWS/Delirium Tremens:
    • Confusion, generalized tonic-clonic seizures, hallucinations, increased temperature linked to psychomotor agitation.
  • Onset Timing:
    • Mild to moderate withdrawal may appear 4-6 hours post-last drink, peaking at 24-36 hours.
    • Severe symptoms can begin as early as 24 hours, usually peaking around day 2.
    • Delirium tremens generally arises after 3 days of abstinence, marked by severe confusion, agitation, and hallucinations.

Withdrawal Seizures

  • Timing: Can occur 12-24 hours post alcohol cessation.
  • Common Treatment: IV diazepam (Valium) is typically administered.

Delirium Tremens (DT)

  • Definition: Medical emergency occurring within the first 72 hours post alcohol cessation.
  • Symptoms:
    • Tachycardia
    • Diaphoresis
    • Fever
    • Anxiety
    • Insomnia
    • Hypertension
    • Delusions with visual/tactile hallucinations.
  • Treatment: Medications such as Valium, Librium, and IV Ativan.

Wernicke’s Encephalopathy

  • Definition: Encephalopathy occurring due to thiamine deficiency.
  • Symptoms:
    • Altered gait
    • Vestibular dysfunction
    • Confusion
    • Nystagmus
    • Lateral orbital palsy
    • Gaze palsy.
  • Treatment: Requires IV thiamine administration for 1-2 weeks.

Korsakoff Syndrome

  • Definition: More severe and chronic form of Wernicke's Encephalopathy.
  • Treatment: Thiamine supplementation required for 3-12 months; however, recovery is often not fully achieved.

Long-term Effects of Alcohol Use

  • Systemic Effects of Alcoholism:
    • Peripheral neuropathy
    • Alcoholic myopathy and cardiomyopathy
    • Gastrointestinal complications including esophagitis, gastritis, pancreatitis
    • Alcoholic hepatitis
    • Cirrhosis of the liver
    • Hematological issues like leukopenia and thrombocytopenia
    • Increased cancer risk, particularly in head and neck regions.

Signs and Symptoms of Alcohol Intoxication by Blood Alcohol Concentration (BAC)

  • 20 mg/dL (0.02 g/dL): Two drinks
    • Effects: Slowed motor performance, decreased cognitive ability, altered mood, reduced multitasking.
  • 50 mg/dL (0.05 g/dL): Three drinks
    • Effects: Impaired judgment, exaggerated behavior, euphoria, and lowered alertness.
  • 80 mg/dL (0.08 g/dL): Four drinks
    • Effects: Poor coordination, altered speech/hearing, impaired judgment, loss of self-control, and decreased reasoning.
  • 100 mg/dL (0.10 g/dL): Five drinks
    • Effects: Slurred speech and slowed cognitive processes.
  • 150 mg/dL (0.15 g/dL): Six drinks
    • Effects: Possible vomiting and significant balance issues (unless high tolerance).
  • 200 mg/dL (0.20 g/dL): Eight to ten drinks
    • Effects: Memory blackouts, nausea and vomiting.
  • 300 mg/dL (0.30 g/dL): More than ten drinks
    • Effects: Severe body temperature, blood pressure, and respiratory rate declines; significant sleepiness, amnesia.
  • 400 mg/dL (0.40 g/dL):
    • Effects: Impaired vital signs; potential for death.

CAGE Questionnaire for Alcohol Use Assessment

  • Questions to Evaluate Alcohol Use:
    • Have you ever felt you needed to Cut down on your drinking?
    • Have people Annoyed you by criticizing your drinking?
    • Have you ever felt Guilty about drinking?
    • Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to alleviate a hangover?

Treatment Options for Alcohol Use Disorders

  • Pharmacotherapy Options Include:
    • Disulfiram
    • Naltrexone
    • Benzodiazepines
  • Psychotherapy: A critical adjunct for successful intervention.

Care Continuum for Substance Use Disorders

  • Stages of Treatment Include:
    • Detoxification (detox)
    • Rehabilitation
    • Halfway houses
    • Other supportive housing options
    • Partial hospitalization programs
    • Intensive outpatient programs
    • Outpatient treatment settings
    • Participation in Alcoholics Anonymous (AA)
    • Focus on relapse prevention strategies.