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85 Cards in this Set
- Front
- Back
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Define addiction:
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a chronic disorder characterized by compulsive use of substances resulting in physical, psychological, or social harm to the user, and continued use despite the harm
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Define Tolerance:
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Physiological adaptation to the effects of drugs so as to diminish effects with constant dosages or to maintain the intensity and duration of effects through increased dosage
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___ is the development of a substance-specific syndrome due to cessation of heavy and prolonged use.
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Substance withdrawals
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What occurs in substance withdrawal?
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- a person quits using something they've used for a long period of time. This causes impaired social, occupational, or physical impairment.
-These are not symptoms of a general medical condition or mental disorder. |
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What is substance intoxication?
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- Reversible substance-specific syndrome
- Clinically significant maladaptive behavior due to substance effect on CNS - not due to other medical or mental disorder |
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Describe the pathways utilized by nearly all abused substances.
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- DA present in mesocrticolimbic system
- Nucleus accumbens to prefrontal cortex, amygdala, and olfactory tube |
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Describe how cocaine alters the reward pathway.
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Block DA reuptake - make DA in the cleft longer
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Describe how opioids alter the reward pathway.
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activate mu receptors resulting in increased release of DA into the nucleus accumbens
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Describe how nicotine alters the reward pathway.
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Interacts with the opioid pathway to activate receptors and increase DA release
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Describe how marijuana alters the reward pathway.
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THC binds to cannabinoid receptors resulting in activation of DA neurons in the mesolimbic system
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Chronic substance abuse results in what effect on DA neurotransmission
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general decrease in DA neurotransmission
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What are the two main explanations for development of substance dependence?
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1. sensitization: increased response following repeated intermittent adminisration of a drug (opposite to tolerance)
2. Counteradaptation: initial positive reward feeling followed by opposing development of tolerance |
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What categorizes substance abuse?
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Any 1 of the following:
- recurrent use causing failure to fulfill major role obligations at home/work/school - recurrent use when physically hazardous - Recurent substance-related legal problems - Continued use despite persistent social/interpersonal problems |
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What categorizes substance dependence?
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Any 3 of the following:
- tolerance - withdrawal - uses more or longer than intended - unable to cut down - use consumes a great deal of time - important social/work activities given up. - Continued use despite physiological or physical problems known to be caused by substance |
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Describe the effects of alcohol & how it works.
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- CNS depressant:
- Dose dependent pattern: sedative, sleep, unconsciousness, coma, respiratory depression, CV collapse) - Affects GABA, glutamate, and DA - Releases endogenous opioids |
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Describe the following related to alcohol:
- Current use - Binge use - Heavy use |
- current use: 1+ drinks in past 30 days
- binge use: 5+ drinks on same occasion at least once in past 30 days - heavy use: 5+ drinks on same occasion at least 5 times in past 30 days |
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Describe the effects of alcohol's interaction with glutamate.
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- glutamate is major excitatory system in cns
- alcohol inhibits glutamate - activation of NMDA receptor = excitation - Inhibition of NMDA = inhibition (sedation, etc) - Chronic ingestion = upregulation of NMDA resulting in hypersensitivity. |
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Describe alcohol as it relates to GABA
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- GABA = major inhibitory system in CNS
- Acute intoxication potentiates GABA inhibition and results in inhibition (sedation, incoordination, etc) - Chronic intoxication down-regulates GABA and results in hyposensitivity |
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HOw does alcohol affect DA?
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- activates mesolimbic dopamine
- results in increased release of DA into nucleus accumbens - positive reinforcement and pleasure |
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Describe assessemnt and treatment for mild and severe intoxication.
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- Mild/Mod: no formal treatment, may present with labile mood, loud behavior, slurred speech, unsteady gait.
- Severe intox: confusion, vomiting, lethargy (0.2-0.3%), stupor, coma (0.3-0.4%), or arrhythmias, respiratory depression, death (>0.4%) - if consciousness impaired Rx = thiamine IV or IM x 3 days |
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What is the CAGE questionairre?
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- Ever needed to CUT down drinking?
- Hever ANNOYED by criticism of drinking - Ever GUILTY about drinking? - Ever needed EYE opener to get going in AM? |
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Name three medications used to treat alcohol dependence?
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- Disulfiram (antabuse)
- Naltrexone (Revia) - Acamprosate (Campral) |
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How does disulfiram work?
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Stops conversion of acetylaldehyde to acetic acid. Acetaldehyde builds up and makes patient very sick
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Describe symptoms of a disulfiram- alcohol reaction.
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- N/V
- HA - HOTN - MI -Weakness - Tachy - SOB - Sweating - Dizziness - Vision changes - Confusion |
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Describe the treatment guidelines for disulfiram.
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- Abstinent from ETOH >12 hours
- Fully effective in 12-14 hours - Need to be off x 2 weeks before using alcohol. |
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Identify predictors of success with disulfiram treatment.
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- Motivation
- Compliance - High Risk Situations (i.e. weddings) - COntingencies (i.e. loss of license) - supervised administration - Stable home life |
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Describe the mechanism and indication of Naltrexone.
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- used for narcotic abuse and alcohol dependence
- alcohol dependence: competetive mu opioid receptor antagonist - blocks B-endorphin which normally stimulates DA release - Blocks ethanol-induced DA release into nucleus accumbens (blocks rewarding effects) |
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Describe reliability information regarding naltrexone for alcohol dependence.
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- Mild-moderate effectivity
- Studies controversial about long-term effectiveness. |
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What is acamprosate? How does it work?
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- used in tx of alochol dependence to maintain abstinence after detox
- restores balance between glutamate and GABA -may decrease glutamate overactivity - Decreases ability of ethanol to activate mesolmbic DA system. |
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How effective is acamprosate?
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Modrerate - similar to naltrexone, 15-30% long term effectiveness at 1 year
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Important considerations regarding side effects and metabolism with acamprosate include:
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- may cause diarrhea, asthenia, anxiety, or insomnia
- Renally eliminated (avoid in pts with CrCl<30dl/ml) - safe with other alcohol treatments |
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Minor symptoms of alcohol withdrawal include:
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- tremor
- N/V - diaphoresis - VS increase - Sleep prolems - hallucinations - seizures (95% have 1 or 0 symptoms) |
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Describe the time course onset of mild alcohol withdrawal.
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Onset: 8-12 hours
Peak: 24-36 hours Duration: 60-72 hours |
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Major symptoms of alcohol withdrawals include:
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- Delirium tremens
- Hallucinations - Agitation - Tremors - Marked VS increases - Marked diaphoresis - Sleep problems |
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Describe the time course onset of major alcohol withdrawals.
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Onset: 40-60 hours
Peak: 72 hours Duration: 120-168 hours |
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Describe treatment goals during alcohol withdrawals.
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- Prevent withdrawal symptoms including Seizures, DTs, medical and psychological complications
- encourage long-term abstinence - encourage/refer to outpt treatment (AA, 12 step programs, etc) |
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What is CIWA-Ar?
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Clinical tools for alcohol withdrawal:
- evaluates need for pharmacologic therapy - <8 no need - 8-15 use med - 15 use med and closely monitor |
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What is the drug of choice for uncomplicated alcohol withdrawal?
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Benzos
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When are benzos given in alcohol withdrawal?
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- score >8, only when symptoms present
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What are long-acting medications used for alcohol withdrawal treatment?
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Chlordiazepoxide (librium)
diazepam (valium) |
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What short-acting medications are sometimes used in treatment of alcohol withdrawal? what patients are these especially useful in?
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- Lorazepam (ativan)
- Oxazepam (Serax) - beneficial in pts iwth liver failure b/c not metabolized by p450 |
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The class drug of choice for alcohol related seizures is ___
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benzodiazepines
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Treatment of Seizures in alcohol withdrawal should include:
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- Benzodiazepine (diazepam IV, lorazepam IM) to stop seizure
- Correction of electrolyte imbalances |
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___ is given for severe agitation unresponsive to benzos in pts with delirium tremens.
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Haloperidol
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Chlordiazepoxide is a ___
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Benzo
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Clorazepate is a ___
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benzo
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Alprazolam is a
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Benzo
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Most benzos produce dependence in ____ days, with wthdrawal onset in ___ Hours and peak withdrawal symptoms in ___ days
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1. dependence 42-120 days
2. withdrawal onset: 12-24 hours 3. peak withdrawal: 5-8 days |
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Describe a simple benzo taper.
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25% dose reduction per week until 50% reached, then decrease by 1/8 q4-7 days
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How long of a taper should be used for benzos given
- >8 weeks - > 6 mos - >1 year |
1. >8weeks: 2-3 week taper
2. >6mos: 4-8 week taper 3. >1 year: consideration given to using long-acting agents |
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Sudden discontinuation of benzodiazepines may result in:
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- rebound anxiety
- recurrence or relapse of symptoms - withdrawal symptoms |
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Describe withdrawal symptoms of benzos.
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- Common: anxiety, insomnia, restlessness, muscle tension, irritability
- Less common: nausea, malaise, vision changes, diaphoresis, nightmares, ataxia, hyperreflexia - Rare: seizures, hallucinations, paranoia, confusion |
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Withdrawal seizures from benzos will typically occur around what time after discontinuation?
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- short-acting: 3 days
- Longer lasting: 1 week |
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Who is most at risk for BDZ withdrawal seizures?
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- High BDZ dose
- long duration of therapy - other concurrent meds that lower threshold |
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Describe symptoms of stimulant intoxication, What drugs are most common causes?
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- Cocaine, methamphetamines, etc
- restlessness, anxiety, euphoria, grandiosity, hypervigilance, tachycardia/ elevated BP, mydriasis, sweats/chills, N/V/D, CVcollapse, psychosis, death |
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Signs of stimulant abuse include:
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- dilated pupils (high dose)
- dry mouth - bad breath - lip licking - decreased appetite and sleep - irritable - talkative - runny/bloody nose - paraphernalia |
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treatment for stimulant intoxication includes:
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- Treat and monitor problems ie hyperthermia, hpertension, arrhytmia, stroke
- Benzos for anxiety - (check for alcohol use, etc first) - referral to therapy, groups, etc - no proven pharmacotherapy (maybe disulfiram for cocaine... maybe) |
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Withdrawal from stimulants often results in ___
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Dysphoric or depressed mood
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Life threatening complications of stimulant withdrawal:
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- seizures
- hyperthermia - ischemic chest pain - suicide |
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Symptoms of Opioid intoxication include:
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- euphoria
- dysphoria - apathy - motor retardation - sedation - attention impairment - miosis |
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Symptoms of opioid withdrawal include:
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- lacrimation
- rhionrrhea - mydriasis - piloerection (goosebumps) - diarrhea - yawning - insomnia - muscle aching |
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opioid intoxication is signified by what symptom? How is it treated?
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- respiratory depression
- tx = naloxone |
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Discontinuation of chronic opioid use may lead to ___.
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- cyclic AMP in adrenergic neurons becomes overactive (opioids inhibit cyclic AMP system)
- Noradrenergic brain activity increases (inc. withdrawal symptoms) |
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What are the 4 grades of opioid withdrawal?
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- Mild (grade I)
- Moderate (grade II) - Marked (grade III) - Severe (grade IV) |
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Describe Grade I opioid withdrawal:
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- Mild (grade I): yawning, lacrimation, rhinorrhea, perspiration, restlessness, insomnia
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Describe Grade II opioid withdrawal:
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- Moderate (grade II): tremors, dilated pupils, goosebumps, anorexia, muscle twitching, myalgia, abdominal pain
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Describe grade III opioid withdrawal.
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- nausea
- extreme restlessness - vital signs increased (tachycardia, HTN, fever) - hot/cold flashes |
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Describe grade IV opioid withdrawals
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- vomiting
- diarrhea - weight loss - dehydration - hypOtension |
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When is opioid withdrawal fatal?
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Not fatal unless medical complications (very uncomfortable still, incapacitating)
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What is the mechanism of clonidine for use in opioid withdrawals?
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A2 agonist- inhibits the opiate withdrawal effects...
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Clonidine should be given for ___ days in heroin cessation and ___ days in methadone cessation.
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10 days heroin
14 days clonidine Both require a taper |
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how does methadone work in opioid withdrawal?
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- Agonist for mu and sigma receptors.
- suppresses withdrawal symptoms - competetive agonist (blocks effect of other opioids |
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Side effects of methadone include:
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constipation, sweating, urinary retention, respiratory depression
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Describe the MOA for buprenorphine.
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- mu receptor partial agonist and weak K receptor antagonist
- similar effects as methadone - opioid antagonist at higher doses - controls cravings due to same sense of euphoria, but not as addictive as heroin wiht unlikely OD |
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When can naltrexone be initiated?
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Pt opioid free for 7-10 days
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Use of naloxone is limited by ___. When is it most useful?
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poor compliance and high drop out rate
- complete antagonist may induce withdrawal. _ most useful in pts who are trying to prevent relapse |
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Describe how nicotine affects the CNS.
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- affects DA, NE, 5-HT, glutamate, GABA, and endogenous opioid peptides
- activates nicotinic ACH receptors |
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Describe the goal of nicotine replacement therapy.
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- get rid of psychological addiction so they can move on to physical addiction parameters
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Pharmacotherapy for smoking cessation include:
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- buproprion
- varenicline - clonidine - TCAs |
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Nicotine replacement (is/ is not) safe in cardiac disease or pregnancy?
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- IS, as long as risk/benefit is favorable.
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Describe the MOA for buproprion in smoking cessation.
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- blocks reuptake of DA and NE.
- non-competetive antagonist on ACH receptor - Reduces nicotine reinforcement, withdrawal, and craving (helps with feel-good for cigarrete.. give 1-2 weeks before quitting, then continue medication) |
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Describe the MOA of varenicline (chantix) in smoking cessation.
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- Agonizes and blocks nicotinic acetylcholine receptors
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What is important to remember for caution in prescribing varenicline?
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Black Box Warning: neuropsychiatric symptoms and suicidiality (weigh risk./benefit) ...esp in teens
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2nd line therapy for smoking cessation includes:
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- clonidine (modest efficacy)
- TCAs (nortriptyline) - inhibit NE reuptake and 5-HT reuptake. |
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What are the disadvantages to TCA use in smoking cessation?
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- anticholinergic burden
- cardiac side effects |
