Tn: Psychiatry 10

Front 1

Epidemiology of substance related and addictive disorders

Back 1

47% of those with substance abuse have mental health problems

29% of those with a mental health disorder have a substance use disorder

47% of those with schizophrenia and 25% of those with an anxiety disorder have a substance use disorder

Front 2

How are substance use disorders measured?

Back 2

On a continuum from mild to severe

• 2-3 criteria is required for a mild substance use disorder diagnosis
  
• 4-5 is moderate
  
• 6-7 is severe
  

Front 3

What is the criteria for substance use disorders?

Back 3

• hazardous use
  
• social/interpersonal problems related to use
  
• neglected major roles to use
  
• withdrawal
  
• tolerance
  
• use large amounts/longer
  
• repeated attempts to quit/control use
  
• use for longer duration/larger amounts than intended
  
• physical/psychological problems related to use
  
• activities given up to use
  
• cravings
  

Front 4

What are the five main depressants?

Back 4

• Alcohol
  
• Opiods
  
• Barbiturates
  
• Benzodiazepines
  
• GHB
  

Front 5

Three main stimulants

Back 5

• Amphetamines
  
• Methylphenidate
  
• Cocaine
  

Front 6

Five main hallucinogens

Back 6

• Cannabis
  
• LSD
  
• PCP
  
• Ketamine
  
• Psilocybin
  

Front 7

Alcohol history?

Back 7

CAGE

C ever felt the need to Cut down on drinking?

A ever felt Annoyed at criticism of your drinking?

G ever feel Guilty about your drinking

E ever need a drink first thing in the morning (Eye opener)?

Men >/= to 2 is +

Women >/= 1 is +

Front 8

Questions to ask in general assessment?

Back 8

• When was your last drink?
  
• Do you have to drink more to get the same effect?
  
• Do you get shaky or nauseous when you stop drinking?
  
• Have you ever had a withdrawal seizure?
  
• How much time and effort do you put into obtaining alcohol?
  

Front 9

Questions (cont) to ask in general alcohol assessment?

Back 9

• Has your drinking affected your ability to work, go to school, or have relationships?
  
• Have you suffered any legal consequences
  
• Has your drinking caused any medical problems?
  

Front 10

What is considered "moderate" drinking for men?

Back 10

3 or less/day (less than or equal to 15/week)

Front 11

What is considered "moderate" drinking for women?

Back 11

2 or less/day (less than or equal to 10/week)

Front 12

What is considered "moderate" drinking for elderly?

Back 12

1 or less drinks per day

Front 13

What is alcohol intoxication?

Back 13

• legal limit for impaired driving is 10.6 mmol/L (50 mg/dL)
  
• this is reached by 2-3 drinks/hour for men and 1-2 drinks/hour for women
  

Front 14

When can a coma occur from alcohol intoxication?

Back 14

• greater than 60 mmol/L (non-tolerant drinkers)
  
• 90-120 mmol/L (tolerant drinkers)
  

Front 15

When does alcohol withdrawal occur?

Back 15

12-48 hours after prolonged heavy drinking and can be life-threatening

Front 16

How to describe alcohol withdrawal?

Back 16

Four stages

Front 17

What is stage 1 of alcohol withdrawal?

Back 17

onset 12-18 hours after last drink

• "the shakes" tremor
  
• sweating
  
• agitation
  
• anorexia
  
• cramps
  
• diarrhea
  
• sleep disturbance
  

Front 18

What is stage 2 of alcohol withdrawal?

Back 18

• onset 7-38 h
  
• alcohol withdrawal seizures
  
• usually tonic-clonic
  
• nonfocal and brief
  

Front 19

what is stage 3 of alcohol withdrawal?

Back 19

• onset 48 h
  
• visual
  
• auditory
  
• olfactory
  
• or tactile hallucinations
  

Front 20

What is stage 4 of alcohol withdrawal?

Back 20

onset 3-5 days

• delirium tremens
  
• confusion
  
• delusions
  
• hallucinations
  
• agitation
  
• tremors
  
• autonomic hyperactivity (fever, tachycardia, HTN)
  

Front 21

What is the course of alcohol withdrawal?

Back 21

almost completely reversible in young, elderly, often left with cognitive deficits

Front 22

What is the mortality rate of alcohol withdrawal?

Back 22

20% if untreated

Front 23

What other forms of alcohol do people ingest other than usual drinks?

Back 23

• mouthwash
  
• rubbing alcohol
  
• methanol
  
• ethylene glycol
  
• aftershave (may be used as a cheaper alternative)
  

Front 24

Features of delirium tremens?

Back 24

• Autonomic hyperactivity
  
• hand tremor
  
• insomnia
  
• psychomotor agitation
  
• anxiety
  
• nausea or vomiting
  
• tonic-clonic seizures
  
• visual/tactile/auditory hallucinations
  
• persecutory delusions
  

Front 25

What to monitor in alcohol withdrawal?

Back 25

• nausea and vomiting
  
• tactile disturbances
  
• tremor
  
• auditory disturbances
  
• agitation
  
• paroxysmal sweats
  
• visual disturbances
  
• anxiety
  
• headache, fullness in head
  
• orientation and clouding of sensorium
  

mild < 10, moderate 10-20, severe >20

Front 26

CIWA-A scale treatment protocol for alcohol withdrawal (basic protocol)

Back 26

• Diazepam 20 mg PO q1-2h PRN until CIWA-A <10 points
  
• observe 1-2 h after last dose and reassess on CIWA-A scale
  
• thiamine 100 mg IM then 100 mg PO OD for 3 days
• supportive care (hydration and nutrition)

Front 27

What is wernicke-korsakoff syndrome?

Back 27

Alcohol induced amnestic disorders due to thiamine disorder

Front 28

Necrotic lesions in wernicke-korsakoff syndrome?

Back 28

mammillary bodies

thalamus

brainstem

Front 29

What is Wernicke's encephalopathy?

Back 29

Acute and reversible

triad of:

• nystagmus (CN VI palsy)
  
• ataxia
  
• confusions
  

Front 30

What is Korsakoff's syndrome?

Back 30

• chronic and only 20% reversible with treatment
  
• anterograde amnesia and confabulations
  
• cannot occur during an acute delirium or dementia
  
• must persist beyond usual duration of intoxication/withdrawal
  

Front 31

How to manage Wernicke's?

Back 31

thiamine 100 mg PO OD x 1-2 weeks

Front 32

How to manage Korsakoff's?

Back 32

thiamine 100 mg PO bid/tid x 3-12 mo

Front 33

Non-pharmacological treatments of alcohol use disorder?

Back 33

• psychotherapy
  
• behaviour therapy
  
• supportive services
  
• inpatient programs (e.g. 28 day programs)
  

Front 34

Psychotherapeutic treatment for alcohol use disorder?

Back 34

• motivational enhancement therapy (MET; increasing motivation to change)
  
• CBT (assertiveness training, increasing social support, planning leisure activities)
  
• marital and family therapy
  

Front 35

Behaviour therapy for alcohol use disorder?

Back 35

• contingency management
  
• community reinforcement approach (CRA)
  

Front 36

Supportive services to treat alcohol use disorder?

Back 36

• counseling
  
• detoxification centers
  
• AA
  

Front 37

Inpatient programs to treat alcohol use disorder?

Back 37

Individual readiness for change must always be considered with non pharmacological interventions

Front 38

Three main pharmacological treatments for alcohol use disorder

Back 38

• naltrexone (Revia)
  
• disulfiram (antabuse)
  
• acamprosate (Campral)
  

Front 39

What is naltrexone?

Back 39

• opiod antagonist
  
• shown to be successful in reducing the "high" associated with alcohol
  
• moderately effective in reducing cravings, frequency or intensity of alcohol binges
  

Front 40

What is disulfiram?

Back 40

• Antabuse
  
• blocks oxidation of alcohol (blocks acetaldehyde dehydrogenase)
  
• with alcohol consumption, acetaldehyde accumulates to cause a toxic reaction (vomiting, tachycardia, death)
  
• if patient relapses, must wait 48 h before restarting antabuse
  

Front 41

What is acamprosate?

Back 41

• Campral
  
• NMDA glutamate receptor antagonist
  
• useful in maintaining abstinence and decreasing cravings
  

Front 42

Types of opioids?

Back 42

heroin

morphine

oxycodone

Tylenol 3 (codeine)

hydromorphone

Front 43

Major risks associated with use of contaminated needles?

Back 43

hep B and C

bacterial endocarditis

HIV/AIDS

Front 44

What happens in acute opioid intoxication?

Back 44

direct effect on receptors in CNS resulting in:

• decreased pain perception
  
• sedation
  
• decreased sex drive
  
• N/V
  
• decrease GI motility
  
• respiratory depression
  

Front 45

What happens in a typical toxic opioid reaction?

Back 45

shallow respirations

• miosis
  
• bradycardia
  
• hypothermia
  
• decreased LOC
  

Front 46

How to manage opioid toxic reaction?

Back 46

• ABCs
  
• IV glucose
  
• nalosone hydrochloride (Narcan): 0.4 mg up to 2 mg IV for diagnosis
  
• treatment: intubation and mechanical ventilation, with or without naloxone drip, until patient alert without naloxone (> 48h with long acting opioids)
  

Front 47

How long might you need to reserve for toxic reaction of opioids?

Back 47

at least 24 h

Front 48

Symptoms of opioid withdrawal?

Back 48

• depression
  
• insomnia
  
• drug craving
  
• myalgia
  
• nausea
  
• chills
  
• autonomic instability (lacrimation, rhinorrhea, piloerection)
  
• 
  

onset: 6-12 h; duration: 5-10 days

Front 49

Complications of opioid withdrawal?

Back 49

• loss of tolerance
  
• miscarraige
  
• premature labor
  

Front 50

Management of opioid withdrawal?

Back 50

• long acting oral opioids (methadone, buprenorphrine)
  
• alpha adrenergic agonists (clonidine)
  

Front 51

Treatment of opioid use disorder?

Back 51

• psychosocial treatment
  
• naltrexone or naloxone
  
• withdrawal maintenance
  
• suboxone
  

Front 52

Psychosocial treatment for opioid use disorder?

Back 52

• Narcotics anonymous
  
• usually emphasize total abstinence
  

Front 53

What might naltrexone or naloxone use for?

Back 53

• These are opiods antagonists
  
• extinguish drug seeking behaviour
  

Front 54

Long-term treatment for opiod use disorder?

Back 54

withdrawal maintence treatment with:

methadone or buprenorphine

Front 55

What is suboxone?

Back 55

• naloxone in addition to buprenorphine
  
• effort to prevent injection of the drug
  

Front 56

Street names for cocaine?

Back 56

• blow
  
• C
  
• coke
  
• crack
  
• flake
  
• freebase
  
• rock
  
• snow
  

Front 57

What is cocaine?

Back 57

• alkaloid extracted from leaves of the coca plant
  
• blocks presynaptic uptake of dopamine (causing euphoria)
  
• NE and E (causing vasospasm, HTN)
  

Front 58

How to self-administer cocaine?

Back 58

• inhalation
  
• intravenous route
  

Front 59

Symptoms of cocaine intoxication?

Back 59

• elation
  
• euphoria
  
• pressured speech
  
• restlessness
  
• sympathetic stimulation (e.g. tachycardia, mydriasis, sweating)
  
• prolonged use may result in paranoid and psychosis
  

Front 60

Symptoms of cocaine overdose?

Back 60

MEDICAL EMERGENCY

• HTN
  
• tachycardia
  
• tonic-clonic seizures
  
• dyspnea
  
• ventricular arrhythmias
  

Front 61

Treatment of cocaine overdose?

Back 61

IV diazepam to control seizures and propanolol or labetalol to manage HTN and arrhythmias

Front 62

What happens in cocaine withdrawal?

Back 62

• initial crash (1-48 h)
  
• withdrawal (1-10 weeks)
  

Front 63

Complications in cocaine withdrawal?

Back 63

relapse

suicide (significant increase in suicide during withdrawal period)

Front 64

management of cocaine withdrawal?

Back 64

Supportive

Front 65

Treatment of cocaine use disorder?

Back 65

psychotherapy

group therapy

narcotics anonymous

behaviour modifcation useful in maintaining abstinence

Front 66

Complications of cocaine use disorder?

Back 66

CV: arrhythmias, MI, CVA, ruptured AAA

neurological: seizures

psychiatric: psychosis, paranoia, delirium, suicidal ideation

Front 67

Amphetamine intoxication characteristics?

Back 67

• euphoria
  
• improved concentration
  
• sympathetic and behavioural hyperactivity
  
• at high doses can cause coma
  

Front 68

Chronic use of amphetamines can result in...?

Back 68

• paranoid psychosis
  
• can resemble schizophrenia with agitation
  
• paranoia
  
• delusions
  
• hallucinations
  

Front 69

withdrawal symptoms of amphetamine use?

Back 69

• dysphoria
  
• fatigue
  
• restlessness
  

Front 70

How to treat stimulant psychosis?

Back 70

Antipsychotics

Front 71

What is the most commonly used illicit drug?

Back 71

Cannabis (marijuana)

Front 72

What is the psychoactive substance in cannabis?

Back 72

delta-9-tetrahydrocannabinol (delta9-THC)

Front 73

Characteristics of cannabis intoxication?

Back 73

• tachycardia
  
• conjunctival vascular engorgement
  
• dry mouth
  
• altered sensorium
  
• increased appetite
  
• increased sense of well being
  
• euphoria/laughter
  
• muscle relaxation
  
• impaired performance of psychomotor tasks including driving
  

Front 74

What might high doses of cannabis result in?

Back 74

• depersonalization
  
• paranoia
  
• anxiety
  
• may trigger psychosis and schizophrenia if predisposed
  

Front 75

What is chronic cannabis use associated with?

Back 75

tolerance

apathetic, amotivational state

Front 76

T/F cannabis cessation produces a significant withdrawal phenomenon?

Back 76

True

Front 77

How to treat cannabis use disorder?

Back 77

behavioural and psychological interventions to main abstinent state

Front 78

Types of hallucinogens?

Back 78

• LSD
  
• mescaline
  
• psilocybin mushrooms
  
• PCP
  
• salvia
  

Front 79

LSD intoxication characteristics?

Back 79

• tachycardia
  
• HTN
  
• mydriasis
  
• tremor
  
• hyperpyrexia
  
• perceptual and mood changes
  

Front 80

Hallucinogen withdrawal syndrome?

Back 80

None characterized

Front 81

Treatment of agitation and psychosis related to hallucinogens?

Back 81

• support
  
• reassurance
  
• diminished stimulation
  
• benzos or high potency antipsychotics seldom required
  

Front 82

PCP mechanism?

Back 82

Not understood

used by vets to immobilize large animals

Front 83

Effect of PCP?

Back 83

amnestic

euphoric

hallucinatory state

Front 84

Adverse effects of PCP use?

Back 84

• horizontal/vertical nystagmus
  
• myoclonus
  
• ataxia
  
• autonomic instability (tx diazepam IV)
  
• prolonged agitated psychosis (haldol)
  
• high risk for suicide
  
• voilence
  
• high doses can cause coma
  

Front 85

Epidemiology of smoking?

Back 85

• single most preventable cause of premature illness and death
  
• 440,000 deaths/yr in US
  
• 70% of smokers see physician each year; 28% receive advise or assistance from physician re: quitting
  
• 70% would like to quit; w/o help only 5% quit
  
• > 95% relapse who try quitting on their own
  

Front 86

general approach to smoking ceasation

Back 86

• ask about smoking, help them quit
  
• every smoker should be offered treatment (counselling and meds most effective)
  
• make patient aware of withdrawal symptoms (low mood, insomnia, irritability, inc. appetite)
  
• >/= 4 counseling session > 10 min, 6-12 mo fu
  
• 14% abstinent w counseling vs 10% w/o counseling
  
• approach depends on pts stage of change
  

Front 87

If pt is willing to quit smoking, what to do?

Back 87

• provision of social support, community resources
  
• pregnant patients: counseling recommended as 1st line tx, limited safety/efficacy of nicotine replacement therapies in this population
  

Front 88

Three main pharmacologic therapies for smoking cessation?

Back 88

1. nicotine replacement therapy (gum, patch, inhaler, nasal spray)
   
2. antidepressants (bupropion SR, nortiptyline)
   
3. Varenicicline (champix)
   

Front 89

Efficacy of NRT?

Back 89

19.7% abstinent at 12 mo with NRT vs 11.5% for placebo

Front 90

Efficacy of bupropion SR and nortiptyline?

Back 90

21% abstinent at 12 mo, vs 8% for placebo

Contraindications: seizure disorder, eating disorder, MAOI use in past 2 wk, simultaneous use of bupropion for depression)

Front 91

Champix efficacy?

Back 91

more effective than bupropion (24% abstinent from 9-52 weeks with varenicline vs 16% for bupropion vs 9% with placebo)

Contraindications: caution with pre-existing psychiatric condition.

Side effects: NV, headache, constipation, increased risk of psychosis, depression, suicidal ideation

Front 92

How to approach pts unwilling to quit smoking?

Back 92

Motivational intervention (5 Rs)

1. relevance to patient

2. risks of smoking

3. rewards: benefits

4. roadblocks: obstacles

5. repetition

Front 93

How to approach recent quitter (smoking)?

Back 93

• Highest relapse within 3 mo of quitting:
  
• minimal practice: congratulate on success, encourage ongoing abstinence, review benefits and problems
  
• prescriptive interventions: address problem of weight gain, negative mood, withdrawal, lack of support