Substance Use Disorders
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What is addiction?
- a primary, chronic , neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations
- characterized by the 5C's
What are the 5 C's?
- control over use impaired
- compulsive use
- continued use despite harm
What is tolerance?
a state of adaption in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.
What is physical dependence?
state of adaptation that is manifested by ta drug class-specific withdrawal syndrome that can be produced by abrupt cessation or rapid dose reduction, decreasing blood levels of the drug and/or by administration of an antagonist
What is substance abuse?
- a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 or more of the following, within a 12-month period:
- recurrent substance use resulting in failure to fulfill major role or obligations at work, school, or home
- recurrent substance use in hazardous situations
- recurrent substance-related legal problems
- continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effect of the substance
What is substance dependence?
- 3 or more of the following present at any time during a 12-month period:
- substance taken in larger amounts or over a longer period than originally intended
- persistent desire or unsuccessful efforts to cut down or control use
- great deal of time spent in activities in obtaining the substance, using the substance, or recovering from the substance's effects
- social, occupational, or recreational activities given up or reduced due to substance use
- substance use continued despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by the substance use
What are the problems associated with substance use disorders?
- health hazards (including walking, driving, etc.)
- acts of violence and/or crime
- impaired judgement and performance - reduced work productivity and performance
- economic burdon to the society
Where does the biology of substance dependence begin?
the mesocorticolimbic system
What effect does alcohol have on the CNS?
What is the relationship between the effects of alcohol and amount consumed?
dose dependent effects
What endogenous substances of the CNS does alcohol affect?
- opiates (euphoria)
What is a standard drink?
- 14g of pure alcohol:
- 12 oz beer
- 8-9 oz malt liquor
- 5 oz wine
- 1.5 oz of spirits (80 proof)
How soon does alcohol absorption begin?
5-10 minutes in the stomach
How long does it take to reach peack serum concentrations?
- 30-90 minutes after the last drink, variable on many factors:
- stomach contents
How is alcohol metabolized?
- > 90% in the liver (alcohol to acetaldehyde in cell to CO2 and H2O by alcohol dehydrogenase)
- < 10% excreted by the lungs, urine and sweat
What is a CAGE questionnaire?
- Cut down (have you ever wanted to cut down on your drinking?)
- Annoyed (if people talk about your drinking)
- Guilty (about your drinking
- Eye opener (do you need a morning drink?)
How do you manage alcohol intoxication?
- assess vital signs, manage resp. depression or BP instability if present, minimize aspiration risk
- maintian in a safe and monitored environment; decrease external stimulation
- measure a BAC; usually measured in mg/dL in the hospital (120mg/dL = 0.12 BAC)
- assess for recent use of other substances that could complicate clinical course
- evaluate for signs/symptoms of withdrawal
What are the specific effects of alcohol related to BAC?
- 0.02 - 0.03 = no loss of coordination, slight euphoria, adn loss of shyness
- 0.07 - 0.09 = slight impairment of balance, speech, vision, reaction time, and hearing. Euphoria. Judgement and self-control are reduced, and caution, reason, and memory are impaired. It is illegal to operate a motor vehicle in some states at this level.
- 0.10 - .0125 = significant impariment of motor coordination and loss of good judgement. Speech can be slurred; balance, vision, rxn time, and hearing impaired. Euphoria. It is illegal to operate a motor vehicle at this level of intoxication.
- 0.16 - 0.20 = Dysphoria(anxiety, resltlessness) predominates, nausea can appear. the drinker has the appearance of a "sloppy drunk".
- 0.3 = loss of consciousness
- 0.4 or higher = onset of coma, possible death caused by respiratory arrest
When do symptoms of alcohol withdrawal typically begin?
within 4-12h or cessation or reduction in alcohol use
What are the sx of alcohol withdrawal?
- hand tremor
- agitation and anxiety
- GI upset
- autonomic hyperactivity
What are the DT's?
- Delirium Tremens:
- intense acute withdrawal characterized by delirium, tremor, tachycardia, hyperthermia
- has been described as "clouding of the consciousness"
- potentially life-threatening
How do you treat alcohol withdrawal?
- all are equally effective
- some are better for certain scenarios though (active/severe liver disease....BZDs are metabolized by the liver)
What are the BZD treatment strategies?
- Symptom-triggered therapy:
- administer CIWA-Ar q h to assess need for meds
- score 10 or more, administer meds such as chlordiazepoxide 50-100mg or lorazepam 2-4mg
- Fixed-schedule therapy:
- May administer q 6-8h
- provide additional meds prn when sx are not controlled
- advantage is nurse knows when to administer
- disadvantage is too much/too little meds being given
Why should you avoid Beta blockers when treating cocaine-induced chest pain?
cocaine is an alpha and beta stimulant. If you block beta, you get excessive alpha stimulation
What other agents may be used to treat alcohol withdrawal?
How do you treat nutritional deficits and electrolyte abnormalities caused by alcohol intoxication?
- replace fluids if dehydrated (avoid overhydration)
- replace electrolytes if indicated
- replace thiamine (often depleted in alcoholics) - 100mg x 3-5d (should be given prior to dextrose administration which can deplete it more)
- replace other vitamins and folic acid as necessary
What problems can thiamine deficiency cause in alcoholics?
- Wernicke's encephalopathy (memory loss)
- Korsakoff's psychoses (fill in holes in memory with fantasy)
What medical complications can be caused by chronic alcoholism?
- fatty liver
- alcohol-induced hepatitis
- acute or chronic pancreatitis
- Wernicke's encephalopathy
- Korsakoff's syndrome
- peripheral neuropathy
- sexual dysfunction
- sleep disorders
- vit B deficiency
- peripheral myopathy
- certain cancers
What drugs are FDA approved to manage alcohol dependence?
- acamprosate (reduce craving)
- naltrexone (reduce craving)
- disulfiram (causes emesis)
What are the formulations of cocaine?
- cocaine HCl
- cocaine base (crack, rock - produced by alkalinizing with NaHCO3)
What are the routes of administration for cocaine?
- inhalation - seconds, 10-15 min high
- snorting - minutes, 20-30 min high
What are the sx of cocaine intoxication?
- motor agitation
- sweating or chills
- pruritis of the nose
What are the sx of cocaine overdose?
- abnormal BP
- cardiac arrest
- resp. depression
What are the sx of cocaine withdrawal?
- sleep disturbances
- changes in appetite
What is the cocaine metabolite tested for in urine screening?
- detected for 12-72h after use (1-3weeks with prolonged/heavy use)
What are the combinations of cocaine used in polysubstance abuse?
- cocaine + alcohol = cocaethylene (more potent)
- cocaine + heroin = speedball
How is acute cocaine intoxication managed?
- tx of hyperthermia, seizures and agitation if present (e.g. BZD)
- management of cocaine-induced cardiovascular complications if present
What are the sx of cocaine-induced cardovascular complications?
- chest pain
What tests are done for cocaine-induced cardiovascular complications?
- cardiac markers
- stress test
How do you treat cocaine-induced ACS?
- ASA, BZD
- IV nitro, nitroprusside (or phentolamine) for persistent HTN
- AVOID BBL in acute setting (excessive alpha stimulation results if only block beta effects of cocaine)
- CCB if not responsive to BZD or nitro
Which alcoholism maintenance drug is nephrotoxic?
acamprosate (if CrCl is not over 30 mL/min)
Which alcoholism maintenance drug is hepatotoxic?
Which alcoholism maintenance drug given once a month?
ER naltrexone (Vivitrol) as a deep IM gluteal injection
What are the sx of opioid intoxication?
- motor retardation
- slurred speech
- attention impairment
How long does it take for daily usage to create tolerance and physical/psychological dependence to opioids?
What is the acute tx of opioid intoxication?
- Naloxone 0.4-2mg IV q 3 min and support vital fx
- if more than 10mg is req'd, investigate other causes
Does tolerance develop to the euphoria caused by opioids?
Does tolerance develop to the constipation and pupil constriction caused by opioids?
Which opioid has the greatest addictive potential?
After what duration of use will withdrawal syndrome occur if opioids are stopped?
several months of steady use
How long after the last opioid dose do drug craving and fear of withdrawal occur?
1-3d after last dose
Insomnia, sweating, and stomach crampsoccur how long after the last opioid dose?
8-14h after last dose
Tremor, vomiting, tachycardia, and HTN occur how long after the last opioid dose?
3-4h after last dose
Why do we use opioids (methadone and suboxone) to manage acute w/d of opioids?
to temporarily use long-acting opioids to reduce the severity of w/d to short-acting opioids
What are the medications used to treat acute intoxication of opioids?
methadone, buprenorphine (with or without naloxone), clonidine
What are the medications used to treat chronic addiction to opioids?
Methadone, buprenorphine (with or without naloxone), Naltrexone, clonidine
Can family doctors prescribe methadone for opioid w/d?
- if admitted to the hospital for non-withdrawal illness
- for 3d in outpatient setting until pt is accepted into a licensed methadone tx program
Can family doctors prescribe suboxone for opioid w/d?
if the doctor recieved training and a waiver to practice opioid addiction tx
Can a family doctor prescribe methadone for pain?
yes, but only 5-10mg
Can a family doctor prescribe suboxone for pain?
yes, should write "for chronic pain" on the script (no X in DEA#, training, or waiver req'd to prescribe for pain)
Can suboxone be abused?
- yes, it can be used by addicts to bridge the gap b/w their regular opioid usage
- the naloxone will only cause w/d if it is injected
How do you check to see if a physician is authorized to write a Rx for suboxone?
What other meds are used to treat acute sx of opioid w/d?
- muscle relaxants
- sleep meds
- drugs for nicotine/alcohol w/d
What is the DOC for maintanance of opioid-dependant pregnant women?
How does naltrexone work in treating opioid addiction?
- pure opioid receptor antagonist
- can cause w/d if pt has recent opioid use (usually started 7-10d after pt begins tx to avoid this)
- for maintenance tx only
How does clonidine work in treating opioid addiction?
- alpha agonist
- helps with anxiety
- shortens duration of w/d sx
- normalizes neurochemistry to make pt less addicted
- helps facilitate methadone w/d
What should you be aware of when using clonidine for opioid addiction?
- typically higher dosing than used for HTN
- potential for hypotension
- taper off to prevent rebound HTN
How does vistaril work in treating opioid addiction?
- similar to clonidine
- reduces anxiety and GI sx
- OFF-LABEL use
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