Addiction Medicine Exam

heroin overdose syndrome most closely resembles

1. end-stage liver disease 2. severe electrolyte disorders 3. conditions associated with acidemia

% of people with SUDs who enter sustained recovery

58%

intrapersonal determinants of relapse identified by Marlatt

A brief cognitive-behavioral therapy (not long-term) Self-efficacy, Outcome expectancies, and craving are all examples of common intrapersonal determinants of relapse Motivation, Coping and Emotional States are all examples of common intrapersonal determinants of relapse determinants of relapse can be modified through treatment Some determinants of relapse are addressed in 12-step programs.

In patients who abuse cocaine _________________ is most commonly abused con-currently with cocaine

ALCOHOL multiple epidemiological studies done on patients who abuse cocaine, the most common substance co-abused with cocaine is alcohol at an astounding 92%! NOT cigarettes, marijuana, or opioids

AUDIT-C vs CAGE

AUDIT-C has been validated and controlled trials of screening and brief intervention and CAGE has not AUDIT-C is shorter than other validated tools and so can be used in the office setting

acamprosate

Acamprosate levels increase when given with naltrexone

Ominous side effect of synthetic marijuana

Acute renal failure

8 to 24 hours

Alcohol withdrawal seizures most commonly occur after patients' last drink

Varenicline (Chantix)

Alpha-4-beta-2-nicotinic acetylcholine receptor partial agonist

MDMA (ecstasy)

Altered perception of TIME

"Complete psychiatric assessment"

Although courts or attorneys may ask for it there is no such thing

Cannabis hyperemesis syndrome

An uncommon adverse effect of chronic marijuana use that occurs in susceptible individuals.

25%

Approximate percentage of nicotine inhaled during tobacco cigarette smoking reaches the bloodstream

50%

Approximate percentage of patients with schizophrenia who abuse drugs or alcohol

nicotine replacement

As an adjunct to group therapy for smoking cessation, nicotine gum nearly doubles quit rates

NO differences

At six-month follow-up of patients who entered rehabilitation after inpatient or outpatient detoxification there were ______________________ noted in use of subsequent alcoholism-treatment services.

PDUQp and SOAPP-R

BOTH are self-administered instruments which screen for the presence of substance use disorders in patients with chronic nonmalignant pain

risk factors is NOT commonly associated with marijuana use

Being Hispanic or African American

risk factors for stimulant abuse

Being involved in a fraternity or sorority Being Caucasian 1 episode of binge drinking in the last 2 weeks Marijuana use in the last month

medications that are induced or inhibited by cytochrome P450 3A4

Benzodiazepines interact with other ketoconazole macrolide antibiotics oral contraceptives

regulating sleep.

Benzodiazepines that stimulate the GABA A α1 subunit

Diazepam and clorazepate

Benzos with the greatest lipid solubility and most rapid onset of action

Rimonabant

CB1 antagonist Developed as an anti-obesity drug Clinical development stopped because of psychiatric adverse events: anxiety, depression, suicidal thoughts

"sleeper effect"

CBT

Excreted mainly in feces

Cannabis

J. W. Huffman

Chemist at Clemson university Developed synthetic forms of cannabis: JWH - 018, JWH - 398, JWH - 250 JWH-250 is the main ingredient of spice found in Germany

In multiple epidemiological studies done on patients who abuse sedatives, which of the following are risk factors for sedative abuse? A. Panic symptoms B. history of IV drug abuse C. Being uninsured D. Marijuana abuse E. Cigarette abuse

Choice D. Surprisingly, marijuana abuse has NOT been found to be linked to sedative abuse.

Varenicline (Chantix)

DO NOT USE IF CAD

EEG patterns observed in cocaine abstinence

Decreased delta and theta with an increase in alpha and beta

NOT risk factor for stimulant abuse

Depression

SLC6A4

Depressive symptoms

Drug Abuse Resistance Education (D.A.R.E.) programs

Don't work Are ineffective at preventing drug and alcohol use

Cocaine works by blocking the

Dopamine Transporter (DT)

18-21 year-olds

Drug abuse programs are most likely to lead to long-term beneficial effects during this developmental period

The most prominent among the military's prevention measures

Drug testing

Anandamide & 2-AG

Endocannabinoids

proton pump inhibitors

False positive UDS for marijuana

soft tissue mobilization

Forceful massage of fascia-muscle system used to reduce contractures

effleurage

Gliding movement of skin without deep muscle involvement

Acamprosate is thought to mediate the activity of channels that are bound by the brain's major excitatory neurotransmitter:

Glutamate via the NMDA receptor

Synesthesia

Hearing colors or seeing sounds LSD

48-72 hours after a single dose and for as long as a week after consumption in persons with heavier use

How long Benzodiazepines metabolites can be detected in UDS

oxcarbazepine.

Hyponatremia may occur in 3%

cocaine use is associated with the highest risk death

IV injection

Contingency Management (CM)

Immediate rewards best Positive reinforcement Engagement in treatment Effective not just for cocaine but also other stimulants alcohol, tobacco, marijuana use disorders, and in drug users from a wide variety of demographic, psychosocial and substance use characteristics Usual recommendation is abstinence from all substances although no clear research evidence exists

End stage liver disease

In addition to heroin overdose, which medical conditions should be considered in the differential diagnosis patients presenting with similar symptoms

OPRM1 gene

In carriers of the 118G allele of the OPRM1 gene, compared with non-carriers: level of dopamine release is induced within the ventral stratum/nucleus accumbens by consuming alcohol Linked to the opioid system, which is involved in the rewarding effects of alcohol through its role in facilitating dopamine release in the ventral stratum No known relationship between OPRM1 and degree of sedative ataxic effects of alcohol

9 out of 10

In multiple research studies conducted on teenage drug abuse, 9 out of every 10 teenagers that became addicted to drugs throughout college started using drugs before the age of 18.

The five "A's"

In order: Ask Advise Assess Assist Arrange follow-up

60%

In patients who use cannabis the likelihood of developing a cannabis use disorder is due to genetic factors

The Matrix Model

Incorporates: individual and group cognitive behavioral therapy, family education, motivational interviewing, and 12 step program participation

nicotine effects

Increased blood pressure (although it extremely high doses it causes low blood pressure) Muscle relaxation Relaxed mood Arousal Enhanced mood, attention & reaction time

SBIRT

Is an evidence-based practice used to a dinner fied, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs It is not being used as it should in the military

7-amino-clonazepam

Main metabolite of CLONAZEPAM

glucuronide

Main metabolite of LORAZEPAM

Cognitive Dissonance

Mental tension when mutually exclusive beliefs about self that motivates modification of thoughts and actions in order to reduce that tension The patient rarely accepts cognitive dissonance because maintaining two opposing views is discomforting The presence of this dissonance gives rise to pressures that reduce it such as changing behaviors such as seeking sobriety

Oxazepam

Metabolite of diazepam, chloridiazepoxide, clorazepate, and temazepam commonly included in standard toxicology urine immunoassay

Naltrexone

Naltrexone does NOT reliably produce long term abstinence from alcohol Naltrexone does produce a reduction in heavy drinking

ALDH5A1

OMT does NOT work

Suicidal thinking and a tamps in gay men and lesbians

Occurs more frequently than heterosexual individuals Increased suicide in gay and lesbian adolescents and young adults

ADVERSE CONSEQUENCES

Oversedation Declining function Intoxication Signs of withdrawal at office visit

Conditioned Tolerance

Paring environmental cues with drug administration

four components of the spirit of Motivational Interviewing

Partnership, Acceptance, Evocation, Compassion

90%

Percentage of teenagers with addiction which started using drugs before they turned age 18

myofascial release

Prolonged light pressure applied in specific directions to stretch focal regions of muscle

Acute tolerance to the effects of opioid drugs is thought to be mediated by:

Protein kinase C phosphorylation of opioid receptors

PMDP's have NOT

Reduced prescription opioid related deaths

Ketamine

Schedule III shorter acting than PCP Spacey feeling "K-hole"

AUDIT-C

Score equal or more than 4 for men is considered positive

Glucocorticoids

Stress may perpetuate the binding of ____________ to dopamine neurons, causing excitation that simulates the action of drugs of abuse.

Specialties with lowest risk of substance abuse

Surgeons and pediatricians

Glutamate

Symptoms associated with acute alcohol withdrawal: tachycardia, tremors, seizures and visual hallucinations, are related to the over activity of this neurotransmitter

Dose

THE dependent factor in zero-order kinetics

Normal human urine

Temperature 90 a 100 F pH 4.5 - 8.5 Creatinine > 20 mg/dL

Delayed discounting

Tendency to choose immediate rewards over larger delayed rewards Both cocaine and methamphetamine abusers show increased delay discounting relative to non-drug users

Inquiry into the Effects of Ardent Spirits on the Human Mind and Body

The 1784 pamphlet by Dr. Benjamin Rush was the first American treatise on alcoholism, and it almost single-handedly launched the American temperance movement

Medical, Philosophical and Chemical on Drunkenness and Its Effects on the Human Body

The 1788 publication by an Edinburgh physician named Dr. Thomas Trotter This publication shared many of Rush's ideas

Which branch of the service operate Substance Abuse Counselling Centers? Air Force National Guard The Marine Corps Army Navy

The Marine Corps

Cortical releasing hormone (CRH), increased BEHAVIORAL reactivity to stress after cessation of heavy alcohol use, brain areas affected

The binding of CRH within the AMYGDALA complex is associated with increased behavioral reactivity to stress after cessation of heavy alcohol use The anterior pituitary mediates the ENDOCRINE response to CRH release--cortisol production--but not the BEHAVIORAL response

Tolerance

The dose response curve is shifted to the right and ED50 is increased

50% to 60%

The estimated heritability of alcohol dependence according to twin studies

The reason there's been little motivation for pharmaceutical companies to produce medications to treat substance use disorders

The existing drugs are not being used as they should

minimum of 1 year

The length of treatment an addiction psychiatrist should recommend when asked by a court to make recommendations for a parolee with a substance use disorder

26% versus 4%

The percentage of teens who use marijuana who progress to the next stage of further illicit drug use, versus the percentage of teens who have never used marijuana (Kandle, 1982)

lorazepam, oxazepam, and temazepam

The three Benzos metabolized only by conjugation

Half-life of the drug

The time it takes a drug, with first-order elimination kinetics, to reach steady state is most dependent on this factor

Naloxone and the newborn

There's going to be a question about NAS and use of naloxone Because it's confusing Mostly naloxone is contraindicated but not if the baby is not breathing or unresponsive Mostly Don't use naloxone

Cyproheptadine

Treatment for serotonin syndrome

Cyproheptadine

Used by athletes to increase weight

Outpatient services

Weakness in the military's approach to treatment of SUDs

Smokers with damage to insula

Were more likely to quit smoking, and stay quit

2 hours

When effects of ingested marijuana PEAK after eating it

44% 56%

______SIPD vs ______ primary psychotic disorder with concurrent substance-induced psychiatric disorder (SIPD)

Tobacco Alcohol, caffeine, and opioids Inhalants

_________________ withdrawal and NOT intoxication can precipitate a sleep disorder. _________________, ___________________, and _____________________ can precipitate sleep disorders both on intoxication and withdrawal. ____________________ are not known to precipitate a sleep disorder during intoxication or withdrawal.

denial rating scale developed by Jeff Goldsmith, MD

a level 2 denial rating = patient states problems are not related to addiction

Percentage of time that patients abuse prescription opioids

about 4.5% of the time

GABRA6

alcohol flushing

ADH1B and ALDH2

alcohol metabolism if mutated, increase the patient's risk of getting an upper GI cancer

Nicotine dependence

alpha-4 beta-2 nicotine receptor channel complex

SLC6A4

amygdala activation psychiatric issues in alcohol abuse

rhabdomyolysis

an uncommon adverse effect of HEROIN use but NOT with synthetic opioids

Rifampin

anti-TB medications when taken with methadone may lead to an increased risk opioid withdrawal symptoms

Caffeine intoxication

anxiety, restlessness, insomnia, gastrointestinal upset, tremors, tachycardia, and psychomotor agitation

1 hour

approximate half-life of cocaine

Hallucinogens -

clear sensorium intact memory hyperalert Visual hallucinations much more than auditory

III.2-D

clinically managed residential detoxification

VNTR

cocaine-induced paranoia

Assertiveness training

commonly incorporated in the treatment of disabled patients with chronic pain. Assertiveness training provides alternative strategies that facilitate relinquishing the sick role.

DIRE

completed by clinicians to aid in predicting the risks of chronic opioid management.

Inhaled cannabis smoke

contains three times the amount of tar compared to tobacco smoke

Stimulants

drug class of drug interaction is most dangerous in persons addicted to cocaine

decreased R.E.M.

effect on sleep architecture in individuals with alcohol use disorder

Stimulants

enhance extracellular concentrations of monoamine neurotransmitters by disrupting function of plasma membrane transporter proteins.

sedative withdrawal results in hypertension from

excess release of norepinephrine

Dextromethorphan

false positive PCP

VNTR

gene involved in cocaine-induced paranoia

CHRNA5

gene involved with smoking cessation and interaction with pharmacotherapy to stop smoking addiction patients with a mutated CHRNA5 gene have a higher chance of getting a smoking addiction while having a lower chance of getting a cocaine addiction

PER1

gene linked to both cocaine addiction and changes in circadian rhythm in cocaine abusers

NMDA receptors

glutamate activates

CAMK4

higher susceptibility to cocaine addiction

Cocaine is associated with:

hyperprolactinemia

28% versus 9%

in twins who abuse marijuana, it was found that the concordance rate was significantly higher for monozygotic male twins compared to dizygotic male twins

Graves' disease

increased risk from cigarette smoking

The Addiction Severity Index (Treatment Research Institute)

is the best studied and validated tool for evaluation of alcohol addiction Better than: DAST-10, CAGE, AUDIT

Pneumocystis (carinii) jiroveci

major pulmonary pathogen in patients with AIDS

Disulfiram (Antabuse)

may cause psychosis

Acamprosate (Campral)

mechanism for maintenance of alcohol abstinence is not completely understood current literature indicates that acamprosate restores the balance of the neurotransmitters glutamate and GABA.

Clonazepam (Klonopin)

metabolism by nitroreduction

Morphine

metabolite of both heroin and codeine

pnuemonia

most common serious infectious disease that occurs in chronic alcohol users

Salvia divinorum

potent and selective κ-opioid receptor AGONIST

AUTS2

prefrontal cortex myriad of different behaviors displayed in patients who abuse alcohol

endocrinological effects of marijuana

problematic hypoadrenalism (heavy use) impair recovery form insulin induced hypoglycemia (heavy use) increases appetite by activation cannabinoid receptors increased risk of lung cancer NO effect on the reproductive systems NO teratogenic or carcinogenic in endocrine organs.

CYP2D6

respiratory depression particularly in European Caucasians who abuse codeine

GHB (gamma hydroxybutyric acid)

rhabdomyolysis

CYP2D6

risk of respiratory depression European Caucasians who abuse codeine.

CAGE

simple, 4-item inventory originally created to screen for alcohol use has been modified for use in detecting drug abuse.

"at-risk drinkers"

those that drink heavily, but suffer no consequences of alcohol abuse or dependence includes potential dangerous situations and heavy drinking is not associated with any adverse effects, except the potential to develop dependence

Absorption

time to onset of action of a specific drug differs by route of administration and is largely dependent this process

Pharmacokinetics

what the BODY does to the DRUG

When methamphetamines are ingested orally, peak plasma concentrations are achieved after

~ 2 hours

%patients who abuse cocaine who eventually develope cocaine dependence

~ 25%

percent of Americans report HEAVY drinking in past month on average

~ 7%

Twelve-month prevalence of opioid use disorder in the US

0.37% That's about 850,000 people

estimated 12-month prevalence for 16-year-old male with inhalant use disorder

0.4%

The number of people with SUD's who receive treatment

1 in 10

atrial fibrillation

1 in 4 lifetime risk for men and women over age 40 Has increased risk of development in heavy alcohol abusers

Match these drugs wth their characteristics 1. Whippet 2. PCP 3. steroids 4. Mescaline 5. Benzene _____ _____ A. B12 deficiency B. Bone marrow suppression C. Nystagmus D. Synthesias E. Gynecomastia

1. A 2. C 3. E 4. D 5. B 6.

In multiple epidemiological studies done on patients who abuse marijuana the most commonly abused substances alongside marijuana in rank order are:

1. ALCOHOL at 90% 2. nicotine 68% 3. cocaine at 12% 4. hallucinogens at 6% 5. opioids at 3%

The Dimension 4 assessment, or readiness for change assessment (ASAM)

1. PRECONTEMPLATION - ACTIVE RESISTANCE 2. CONTEMPLATION - AMBIVALENT 3. PREPARATION - INCREASING CONFIDENCE in the decision 4. ACTION - DROPOUT needs encouragement 5. MAINTENANCE - CONSOLIDATE GAINS 6. RELAPSE & RECYCLING - AVOID BECOMING STUCK 7. TERMINATION - Ultimate stage for all changers, person exits cycle of change without fear of relapse. Some problems terminated while others are kept in remission through ongoing maintenance efforts

PMPD's have

1. Reduced opioid prescribing 2. Reduced "doctor-shopping"

The four into related areas upon which the therapeutic community (TC) perspective is built

1. the substance use disorder 2. the individual 3. the recovery process 4. right living

Caduceus groups

12-Step program designed especially for medical professionals

In multiple epidemiological studies done on patients between the ages of 15-64 who use marijuana at least once a year

160 million people = 4%

According to data from 2013, approximately how many people aged 12 and older tried cocaine for the first time each day in 2013?

1600

The Mysteries of the Opium Reveal'd

1701 the English physician John Jones exceptionally detailed account of opiate withdrawal in his book

In adults over the age of 65, alcohol or substance use may be a problem for _______% of this population.

19%

Severity of Substance Use Disorder by DSM-5

2-3criteria = mild 4-5 criteria = moderate 6 or more criteria = severe

multiple epidemiological studies done on high schoolers who abuse methylphenidate between ______________ % of them abuse the drug on a yearly basis.

2-5%

In 2013 US population aged 12 years and older with illicit drug abuse or dependence (now called substance use disorder per the DSM-5):

2.6%

an example of harmful drinking, as described by the National Institute on Alcohol Abuse and Alcoholism

3-5 drinks on an episodic or daily basis

Iikelihoods of developing Opioid Use Disorder (OUD)

3-fold increased risk with acute low-dose opioids (1-36 mg/day MME) 122-fold increased risk with chronic high-dose opioids (>= 120 mg/day MME)

Dawson et al. reported from a national U.S. community sample that:

3.1% of persons meeting lifetime criteria for alcohol dependence had attended 12-Step meetings 5.4% had had treatment only, and 17% had participated in both 12- Step meetings and treatment.

CB1 receptors

40% homology with CB2 receptors Endocannabinoids are molecules produced in the body and bind to both CB1 & CB2 receptors

Studies consistently confirm a _____________ hereditary risk factor for alcohol abuse disorders.

40-50%

How long do the effects of ingested marijuana last after eating it?

6 hours

According to the 2012 monitoring the future study ( MTF), what percentage of high school seniors smoke marijuana daily or almost every day?

6.5% Or one out of every 15 high school senior

Medication compliance rates

75% for short-term prescriptions 50% for long term prescriptions

In 2013 US population aged 12 years and older with some form of alcohol, illicit, or other substance abuse or dependence (now called a substance use disorder per the DSM-5):

8.2%

NESAR study: estimated past 12 month prevalence of SUDs in the US

9.35%

Link these antiretrovirals with their common side effects A. Efavirenz B. Zidovudine C. Ritonavir D. Lopinavir E. Nevirapine

A. Anxiety, depression, suicidal ideation, confusion, hallucinations B. Mania, agitation, insomnia C. When combined with lopinavir can cause opioid withdrawal symptoms and patients taking methadone and when combined with atazanavr can cause increased drowsiness and cognitive dysfunction in patients taking buprenorphine D. In combination with ritonavir, and in patients on methadone maintenance treatment, can induce opioid withdrawal; BUT for patients treated with buprenorphine--even though this same combination markedly reduces buprenorphine plasma concentrations--no opioid withdrawal symptoms occur E. In combination with efavirenz, and in patients on methadone maintenance treatment, can induce opioid withdrawal; BUT for patients treated with buprenorphine--even though this same combination markedly reduces buprenorphine plasma concentrations--no opioid withdrawal symptoms occur

Link the following specialties with the most commonly abused drug A. Anesthesiologists B. Emergency medicine physicians C. Psychiatrists

A. Opioids B. Illicit drugs C. Benzodiazepines

In a patient with co-occurring bipolar disorder and alcohol use disorder, which of the following medications has the most evidence to support its use in addressing both mood symptoms and drinking outcomes? A. Valproic acid B. Lithium C. Quetiapine D. Aripiprazole E. Lamotrigine

A. Valproic acid Carbamazepine would also be correct

HALT

AA & Twelve-Step Facilitation used when reviewing psychiatric symptoms or substance use or craving since the last visit stands for: Hungry, Angry, Lonely, Tired

genes involved in alcohol metabolism and if mutated, increase the patient's risk of getting an upper GI cancer

ADH1B and ALDH2

NMDA receptors

Activity involved in tolerance Ketamine of acts here OIH involves glutamat-mediated activation of

Cocaine

Acute kidney injury secondary to thrombocytopenic microangiopathic hemolytic anemia

Disulfiram (Antabuse)

After consumption of 1 alcoholic beverage, disulfiram-alcohol reaction can occur immediately and last >2 hours Disulfiram inhibits the conversion of acetaldehyde to acetyl-coenzyme A by inhibiting the enzyme aldehyde dehydrogenase causes a 5-10x increase of acetaldehyde upon the consumption of any alcoholic beverage disulfiram-alcohol reaction = nausea, vomiting, headache, flushing, sweating, tachycardia, chest pain, vertigo, and blurred vision reaction can last as long as alcohol is present in a patient patient cannot develop tolerance to disulfiram estimated half-life of disulfiram is 60-120 hours can cause an aversive reaction with just a small amount alcohol (as little as a 12-ounce beer or 4-ounce glass of wine) disulfiram-alcohol reaction ceases after a patient has stopped taking disulfiram for over 2 weeks. With disulfiram's half-life of 60-120 hours, the patient can replenish aldehyde dehydrogenase and metabolize acetaldehyde after 2 weeks of sobriety from the medication.

acute ethylene glycol toxicity

Although calcium oxalate crystals previously were thought to be the most significant cause of renal toxicity, much of ethylene glycol's nephrotoxic effect is known to stem from the direct cytotoxic action of the organic acid metabolites 33% have hypocalcemia most likely caused by calcium precipitation with oxalate Freshly voided urine fluorescence with a Wood's lamp, may be seen 6 hours after ingestion Crystalluria = hallmark of ethylene glycol ingestion Monohydrate crystals are thought to be more specific than dihydrate crystals

there are no specific rigorously tested criteria to determine level of care

Although several criteria are clinically used for outpatient treatment of AWS: mild to moderate withdrawal symptoms, no medical or neurological illness, no infection, psychiatrically stable, no history of seizures or delirium tremens, reliable support person (for care and transport), easy access to clinic, and need to assess daily

Physician specialists with the highest risk of substance-abuse

Anesthesiologists Emergency medicine physicians

Ketamine

Anesthetic Dissociative Hallucinogen Perceptual distortions, changes in the sense of time and space, alterations and body awareness Promotes long-term abstinence in both alcohol and heroin dependent patients Produces rapid anti-depressant effects that are clinically robust in patients with treatment resistant major depression

Drug discrimination is an animal model for which of the following drug related phenomena in humans? A. Dependence B. Relapse C. Rewarding effects D. Subjective effects E. Tolerance

Answer is D subjective effects

Which of the following is most accurate neural biological explanation for the various alcohol withdrawal syndromes? A. Upregulation in the GABA receptor complex leading to neuronal hyperexcitability B. Downregulation in the GABA receptor complex leaving to neuronal inhibition C. Down regulation of the NMDA receptor complex leading to neuronal hyperexcitability D. Upregulation of the NMDA receptor leading to neuronal hyperexcitability E. Upregulation in the NMDA receptor leading to neuronal inhibition

Answer is D. Upregulation of the NMDA receptor leading to neuronal hyperexcitability

Personality disorder with highest cooccurrence with substance use disorder

Antisocial personality disorder

Dextromethorphan

Antitussive 120 mg or less PCP-like at doses 300 - 1800 mg Main metabolite DXO is weak σ-opioid agonist and stronger NMDA antagonist than DXM Relatively inactive at μ-, δ-, κ-opioid receptors can cause respiratory depression at massive doses Dizziness, slurred speech, blurred vision, drowsiness Nausea and vomiting, hypertension, diaphoresis Euphoria and hallucinations Increased synthesis and release of serotonin serotonin syndrome

Most common coexisting psychiatric disorder in adolescents and in adults

Anxiety disorder

Smoking and co-existing mental disorders

BOTH current AND past smoking are associated with onset of major depression in people ages 15 and older ONLY current smoking is associated with onset of panic disorder, agoraphobia, and substance use disorders.

Cannabis use is associated with:

Being male, Native American, and separated or widowed or divorced, having a lower SES, and living in the Western states

Stimulant use is associated with:

Being young, female, and white or Hispanic with increased use in Western and southwestern states of the United States

preferred method of detection for interpretation of acute effects or to measure quantitative levels of THC

Blood analysis

Match the service branch with the drug prevention program it operates ____ Air Force ____ Army ____ Navy ____ Marine Corps A. SARP (substance abuse rehabilitation programs) B. SACCs (substance abuse counseling centers) C. ADAPT (Alcohol and Drug Abuse Prevention and Treatment) D. ASAP

C, D, A, B

The National Epidemiologic Survey on Alcohol and Related Conditions reported that the prevalence of nicotine dependence was which of the following? A. 5.7% B. 6.8% C. 12.8% D. 16.5% E. 19.8%

C. 12.8%

clonidine

Central α-2 agonist

5%

Chance that Patients addicted to opioids borderline disorder.

TTC12 and ANKK1

Chromosome 11 Associated with alcohol dependence

physiology of alcohol withdrawal

Chronic ETOH = reduction in GABA receptor function and upregulation of the NMDA receptor Stopping ETOH = overactivation of the excitatory NMDA system relative to the GABA system

Benzodiazepines

Chronic ingestion of benzodiazepines results in conformational changes in the receptor site that result in decreased GABA activity

"Blunts"

Cigars which of been hollowed out and filled with marijuana

Methamphetamine (MA) versus cocaine

Cocaine acts primarily by blocking the reuptake of released dopamine in the synaptic clefts of the mesolimbic dopamine neurons MA also blocks the reuptake of released dopamine in the synaptic clefts of the mesolimbic dopamine neurons BUT MA is also carried into the dopaminergic neurons, and unlike cocaine, exerts its primary action intracellularly MA causes docking of the intracellular dopamine-containing vesicles at the membrane leading to leakage of dopamine into the synaptic cleft

Peak lifetime drug use occurs between these ages A. 10-13 B. 14-17 C. 18-21 D. 22-25 E. 26-29

Correct: C. 18-21

Current use of which of the following substances has been increasing among adolescents after a period of decline? A. Cocaine B. Heroin C. Marijuana D. Nicotine E. Phencyclidine (PCP)

Correction: C. Marijuana All the rest have been in decline since 2002

naltrexone extended-release injection

Dose adjustment NOT required in subjects with mild or moderate hepatic impairment

change in use of each substance named in choices above between 1998 and 2014:

E-cigarettes- first measured in 2014 Marijuana- stable Vicodin- decrease Hookah - increase Alcohol- decrease Cigarettes- decrease Inhalants- decrease Adderal - increase

Impending major withdrawal from acute ETOH intoxication could be managed by any of these EXCEPT: A. Phenobarbital B. Whiskey C. Diazepam D. Paraldehyde E. Imipramine

E. Imipramine

Nicotine

Enters the brain within 7 to 15 seconds after inhalation Levels rapidly decline over 20-30 mins Half-life is two hours Nicotine initially stimulates the reward of circuitry of the brain But chronic nicotine exposure may lower stress tolerance by sensitizing brain structures and pathways involved and stress reactivity - - most notably the HPA pathway and amygdala

acupressure

Finger pressure applied over acupuncture points to decrease pain

HALLMARK of drug prevention strategies in family-based prevention programs

Focusing on family bonding and opening up family discussions

gene involved in alcohol flushing

GABRA6

1st grade

Grade at which best to intervene with a program called the classroom-centered (CC) and family-school partnership (FSP) to reduce violence and aggressive behavior in children that may lead to potential future drug abuse

gene associated with cocaine abuse, not alcohol abuse.

H3K9me3

A cluster of nicotinic receptors genes on a chromosome 15

Has been linked with susceptibility for nicotine dependence

MDMA (ecstasy)

Has both stimulant and mild hallucinogen effects.

THC potency from highest to lowest

Hash oil (15-50)-->sinsemilla (7-14%)-->hashish (2-8%)-->marijuana made from the stems & leaves (0.5-5%)

4 to 7 hours

How long the effects of ingested marijuana last after eating it

15

In patients with variation in CNR1 gene with greater than 15 AAT repeats may be at increased risk for addiction to marijuana and other illicit drugs most frequently studied CNR1 polymorphisms is the AAT repeat in the 3' untranslated region of the gene, a variable number of tandem repeats with unknown functional consequence

Absorption

In pharmacokinetics refers to the fraction of unchanged drug that reaches the systemic circulation following administration by any route.

30 minutes, 2 to 4 hours

In studies done on patients who abuse marijuana, the effects of inhaled usage are felt at peak levels about __________________________ after use and last anywhere from _______________________________.

Nicotine absorption

Increased with HIGHER pH acidic decreases oral absorption (i.e., sodas, coffee)

Bupropion (Wellbutrin)

Increases dopamine AND norepinephrine

Bupropion (Wellbutrin)

Increases dopamine and norepinephrine

30 minutes

Inhaled cocaine: approximate duration of action in the body

ETOH effects on brain

Initially, alcohol appears to excite dopaminergic neurons in the ventral tegmental area (VTA0 of the midbrain, including the nucleus accumbens, olfactory tubercle, frontal cortex, amygdala, and the septal/hippocampal areas = the neurons that regulate the excitatory glutamatergic pathways within the mesolimbic and mesocortical areas of the forebrain. alcohol acutely enhances the firing rate of the dopaminergic neurons but chronic exposure= reduction of excitability in the absence of alcohol Alcohol affects a number of neural pathways: the GABA, glutamate, dopamine, serotonin, opioid, and cannabinoid neurotransmitter systems. Alcohol increases endogenous endorphin levels creating euphoria by stimulation of opioid receptors Serotonin levels in the cerebral spinal fluid are reduced in many people who abuse alcohol Serotonin deficiencies are linked to disorders characterized by a loss of behavioral control suggesting reduced serotonin levels and serotonin-mediated neurotransmission may predispose some individuals to uncontrollable drinking behaviors.

Treatment that has been best supported with evidence has been effective for patients with co-occurring SUD's and other psychiatric illnesses

Inpatients treatment

Renal excretion of amphetamines

Is enhanced by acidification of the urine, and reduced by alkalinization of the urine

Naltrexone can cause anxiety early and treatment because of what process?

Its effect on hypothalamic - pituitary - adrenal (HPA) and hypothalamic - pituitary - gonadal (HPG) activity Opioid antagonist's increase HPA activity and alter HPG functioning by blocking the tonic, inhibitory effects of beta endorphins on the hypothalamus Increased HPA activity or stress reactivity may also contribute to the anxiogenic effects of naltrexone experienced by some patients Although nausea, insomnia, headache, and appetite disturbances are common side effects these are not primarily due to HPA and HPG mediated effects

48 to 96 hours

Length of time a newly abstinent, seriously heroin-dependent person can expect to experience the most intense signs and symptoms of withdrawal

AWS

Less than 10%-20% requires inpatient After outpatient detox rate of continuation of patients into rehabilitation program is about 50%

Communities that care (CTC)

Limited: Data from students followed from the fifth to the 10th grade and 24 small to medium size communities

Clonidine HCl

Locus ceruleus Activates alpha 2 adrenergic receptors

alpha-hydroxy-alprazolam

Main metabolite of ALPRAZOLAM

inhibit neurotransmission by hyperpolarization of the cell membrane

Mechanism of action of benzodiazepines

gambling disorder

Men with gambling disorders more likely to be single and live alone Married men more likely to experience consequences of gambling Men more likely to have antisocial personality Men more likely to seek help Women = about 32% of pathological gamblers Women progress more quickly to severe problems related to gambling

30 minutes

Methamphetamine: When injected into the bloodstream approximately how long after injection peak plasma concentrations achieved

MDMA (ecstasy)

Methylenedioxymethamphetamine Hallucinogen "entactogen" Taken orally and tablet or capsule form Effects begin 30 to 60 minutes lasts 4 to 6 hours Promotes increases in positive mood as well as feelings of interpersonal openness, trust, and empathy Dilated pupils, increased heart rate and blood pressure Has been found beneficial in PTSD

Alcohol Withdrawal Syndrome (AWS)

More patients complete inpatient treatment compared to outpatient treatment

1:25

Morphine dilution for infant with NAS

how many people with SUDs who eventually abstain or manage to control their use WITHOUT professional help

Most

What proportion of people who resolve alcohol-related problems do so without formal treatment?

Most (as many as 75%)

Flashbacks

Most common chief complaint resulting from chronic hallucinogen use

generalized anxiety disorder (GAD)

Most common co-occurring psychiatric disorder for patients with Alcohol use disorder

Inhalants

Most common in 12-17 years-olds Use declines with age Positively correlated with: -- bashfulness and shyness -- antisocial behavior -- emotional outburst Native Americans, Hispanic Americans and white Americans of Appalachia are more affected than blacks Disproportionately involves Hispanic youths May be stronger predictor of future use of heroin or cocaine than early marijuana use

More than 10 years

Most common length of sobriety among AA members according to the latest Alcoholics Anonymous survey

bipolar disorder

Most likely Axis I Disorder to co-occur with SUD ECA -- Epidemiological Catchment Area study Higher than: schizophrenia, major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder

According to DSM-5, to diagnosis cannabis intoxication

Must have at least two of the following signs, developing within 2 hours of cannabis use: Conjunctival injection Increased appetite Dry mouth Tachycardia

NIATx

Network for the Improvement of Addiction Treatment 5 principles 1) Involve customers in identifying and correcting problems 2) address problems in key leadership tied to the organizational strategic plan 3) identify and support a powerful change leader that will implement improvements in organizational policies 4) adopt outside the industry promising practices to your organization 5) Use the rapid plan-do-study-act (PDSA) action to evaluate and implement beneficial processes that improve patient care.

Talk about network therapy (NT)

Office based, outpatient treatment for substance use disorders Best characterized as individual therapy, not as group therapy nor family therapy nor 12 step facilitation, nor intervention Must achieve detoxification first Different from group therapy because in group therapy group members use the group therapy sessions for their own treatment where as network members do not Intervention is not used; network members are to support the individual undergoing treatment, not confront The most likely thing to make NT work is the availability of greater social supports to the patient Includes these treatment modalities: CBT, CM, TSF, ME, but NOT intervention It's not for people with no social support such as homeless Best candidate is someone who has trouble with the relapsing but wants to quit

Tamoxifen

Often combined with anabolic - adrenergic steroids to reduce undesirable side effects

According to the NESARC,

Only with minority with substance abuse or dependence report using treatment services 8.1% of those with lifetime drug abuse report receiving treatment 37.9% of those with lifetime drug dependence report receiving treatment For alcohol it's even lower: 7.0% among those with lifetime alcohol abuse 24.1% for those with lifetime alcohol dependence Among those with illicit drug use disorders treatment is positively associated with having psychiatric disorder comorbidity

Motivational Interviewing OARS technique

Open-ended questions Affirmations Reflective listening Summaries

OARS

Open-ended questions Affirmations Reflective listening Summaries Part of the motivational interviewing or motivation enhancement treatment For people in pre-contemplative stage or ambivalent about their drug use and not for people who are contemplating quitting

Mechanisms of action for drugs of abuse

Opioid receptor agonist Dopamine transporter inhibitor GABA-A receptor agonist NMDA glutamate receptor antagonist

methamphetamine abuse

Over 70% of MA-dependent women report histories of physical and sexual abuse Women are more likely than men to present for treatment with greater psychological distress Rate of hepatitis C infection was 15% among all MS-using patients seeking treatment, but those who injected MA over 45% infected with hepatitis C Rates of HIV seroprevalence have been reported to be three times higher among MA using MSM then among the non-MA-using MSM 63.7% of adolescent female seeking treatment reported MA as their primary drug of choice Injection users both men and women have higher dropout rates & exhibit higher rates of MA-using during treatment compared with non-injection users

besides ETOH, other known NMDA antagonists are

PCP ketamine nitrous oxide

ALDH5A1

POOR or NO response opioid maintenance therapy

CB1 receptors

PREsynaptic Primaries CNS

Mental illness and smoking

People without mental illness: 20% Schizophrenia: 70 to 88% ADHD: 40%

25%

Percentage of adolescents who use cannabis to progress to use additional illicit substances

40%

Percentage of all patients who come to the ED as a result of cocaine abuse which presents with chest pain

Adverse selection

Persons with history of SUDs and mental disorders--i.e., persons more likely to become addicted to opioids--were more likely to be prescribed opioids for chronic pain

Alcohol dependence--usual course

Recent research studies have revealed that over 70% of adults with a diagnosis of alcohol dependence experience a single heavy drinking period, lasting an average of 3-4 years Most recover without professional treatment or involvement in mutual help groups In those relapsing after one attempt, tend to experience on average 5 attempts with decreasing drinking periods in between attempts. This suggests, that those that do not control their drinking after the first attempt, will have a chronic course.

Sequence of physiological/molecular events leading to the synaptic plasticity that underlies addiction

Reduction in inhibitory G-protein levels Then Increased cyclic adenosine monophosphate (cAMP) levels then Increased protein kinase A (PKA) activity then cAMP response element binding protein (CREB) regulation of gene expression Then Synaptic plasticity

Forbids any government agency that receives federal funding from engaging in discrimination of any kind

Rehabilitation Act of 1973

True

Review of multiple randomized trials comparing different lengths of inpatient or residential treatment has shown that there is no difference in outcome

Phencyclidine (PCP)

Selectively reduces excitatory actions of glutamate at the NMDA receptor

The evidence base regarding the outcome of inpatient treatment

Several uncontrolled studies found abstinence rates ranging from 25% to 60% For patients with, current psychiatric disorders the rate is more like 25% There have been NO randomized controlled trials that examine abstinence rates

general anxiety disorder, panic disorder, and major depression, dependent personality disorder, neuroticism, high initial anxiety or depression, and decreased education level.

Significantly greater sedative-hypnotic withdrawal symptoms have been found in patients with these psychopathologies

"Speed balling"

Simultaneous use of cocaine and opioids

Referral by a healthcare provider

Since 2011 this is the most common means of referral to Alcoholics Anonymous (40%) Higher than self referral (29%), referral by another AA member (34%), referral by court order (4%), or referral by family (12%)

differentiate patients with cocaine-induced psychosis from patients with acute schizophrenia

Somatosensory hallucinations: COCAINE Bizarre delusions: ACUTE SCHIZOPHRENIA Alogia, a negative symptoms: ACUTE SCHIZOPHRENIA

Stages of AWS

Stage 1: mild symptoms, not associated with normal vital signs Stage 2: symptoms are more intense Stage 3: delirium tremens or seizures.

Previous alcohol or cocaine abuse

Strongest predictor of opioid miss use and chronic pain patients NOT PREDICTIVE of OPIOID MISUSE: gender, race, literacy, disability, pain scores, socioeconomic status

Acupuncture

Studies from the 1970s and since then have revealed that electroacupuncture (acupuncture combined with electrical stimulation) could ameliorate opioid withdrawal symptoms Some studies have shown that acupuncture has improved tachycardia, not caused it Acupuncture-induced analgesia is blocked by naloxone, but NOT naltrexone. This suggests the involvement of endogenous opioid substances with acupuncture Acupuncture was considered promising for the treatment of alcohol addiction in the 1980s, but subsequent trials found that ear acupuncture did not make a significant contribution above that achieved by conventional treatment in the reduction of alcohol abuse.

GABRA2

Studies have been somewhat mixed but many have shown significant associate the rest for alcohol dependence Problem is these associations are weak

Examples of neuroadaptation

Synapses will strengthen for a short time because of an increase in the size of the readily-releasable pool of a packaged neurotransmitter Synapses that have coincident firing are strengthened, whereas other synapses on the same neurons remain unchanged Inputs that cause a post-synaptic neuron's excitation are made even more likely to contribute in the future, whereas inputs that are not casual become less likely to contribute in the future

friction massage

Technique used to prevent adhesions in acute muscle injuries

Controlled Substance Act (CSA) congress enacted in 1970

The prevailing law today created Schedule I - V enhances the "balanced" strategy that combine supply reduction (enforced by police) and demand reduction (prevention, treatment and research).

7% to 16%.

The prevalence of adult alcohol abuse in the United States

15%.

The probability of becoming dependent on alcohol after one use

9%

The probability of becoming dependent on anxiolytics or cannabis after one use

17%.

The probability of becoming dependent on cocaine after one use

23%

The probability of becoming dependent on heroin after one

Treatment of cocaine addiction

There are no FDA approved medications Bupropion plus contingency management has been shown to reduce cocaine use more effectively than either treatment alone or placebo Bupropion is a weak dopamine and norepinephrine reuptake inhibitor and it enhances extracellular dopamine levels in the nucleus accumbens It did not work by itself but only with contingency management Topiramate plus amphetamine salts has been shown to reduce cocaine use compared with placebo NAC, N-acetyl cysteine, A medication used for the treatment of acetaminophen overdose, targets brain glutamate. NAC has shown some positive results in small clinical trials for cocaine addiction D-amphetamine reduced drug use in short term clinical trials in cocaine users Mixed results with methylphenidate and modafinil CBT often used but some studies have failed to show it works Contingency management is the only thing that shows the most positive results 12-step may help

Disadvantage of oral anabolic steroids

They can increase liver function tests

75-80%

Treatment success rate for physicians with substance use disorder These rates are far higher in those reported for general treatment populations

Aftercare has been shown to be more efficacious then no aftercare following treatment for substance use disorders in teens True or false

True

Brief phone intervention was as efficacious as a personal session for aftercare outcomes in teens who completed a substance use disorder treatment program True or false

True

Psychotic symptoms are not associated with FASDs

True

Dextromethorphan

Uncompetitive NMDA receptor (PCP site) ANTAGONIST σ1 & σ2 receptor AGONIST μ-, δ-, κ-opioid receptor AGONIST 10-times more potent metabolite = dextrophan

Furosemide, probenecid

Used in people who abuse anabolic steroids to mask urine testing

DTs

Usually begins 2 to 4 days after the last drink On average lasts one week or less but there have been reports of cases lasting weeks to months Occurs in 5% of patients admitted for alcohol withdrawal Mortality rate can be as high as 20% for those not receiving proper and adequate treatment

NSDUH Study 2003

Whites 2 times as likely to get addicted to opioids as African-Americans Patients with depressive symptoms for two weeks prior to initiation of opioid treatment had 2.5 times increased likelihood of opioid addiction Patients with any pre-existing mental health disorder had twice the risk of opioid addiction

Opioid receptors are:

a group of inhibitory G protein-coupled receptors ~40% identical to somatostatin receptors (SSTRs) distributed widely in the brain, and are also found in the spinal cord and digestive tract

meta-analysis

a procedure for statistically combining the results of many different research studies effect size, and NOT statistical significance, is the basic unit of analysis most often used

Difluoroethane

abused inhalants is commonly found in compressed "air" dusters for computers

Hallucinogens

act through the 5-HT2A receptor, which couples to Gq proteins and inositol triphosphate (IP3) and leads to intracellular calcium release. act by enhancing excitatory AFFERENT input from the thalamus and INCREASING glutamate release in the cortex activate primarily the serotonin system

According to the 2014 Monitoring the Future Study of the use of substances by youth in the U.S., which pair of drugs were associated with a decrease in use among all grades since 1998?

alcohol & tobacco

An important brain region that mediates the salience of pain is the

amygdala

SLC6A4

amygdala activation psychiatric issues in alcohol abuse.

Ketamine is

an NMDA receptor antagonist

CRAFFT

an instrument to detect substance use in the youth 6-questions: Car, Relax, Alone, Forget, Friends, Trouble easy-to-use validated endorsed by the NIDA and the AAP can discriminate between substance use, at-risk use, and disorder in adolescents

Basal Ganglia and Hippocampus

areas of the brain has the highest concentration of cannabinoid receptors

CYP2A*7 allele

associated with reduced metabolism and clearance of nicotine People with this genotype smoke fewer cigarettes per day and tend to start smoking at a later age Patients with this genotype, however, are less likely to stop smoking

CYP2A6*9 allele

associated with reduced nicotine metabolism patients with this variant tend to smoke fewer cigarettes per day and they tend to start smoking at a later age overall patients with this genotype are less likely to quit smoking response to nicotine administered via transdermal patch is better

levo-alpha-acetylmethadol (LAAM)

associated with torsade de pointes The reason why it is no longer used for opioid maintenance treatment

0.5 mg

average dose of nicotine delivered by smoking one average cigarette

Pentobarbital

barbiturate with the quickest onset of action

30 to 60 minutes

behavioral effects of COCAINE: approximate duration of intoxication or high

Clonidine HCl

blocks activation of the locus ceruleus

Disulfiram (Antabuse)

blocks dopamine-beta-hydroxylase in brain

Buprenorphine: pregnancy & lactation

buprenorphine maintenance produces a less intense withdrawal in newborns compared to methadone However, methadone therapy improves outcomes in pregnant women who are dependent on opioids Buprenorphine is a category C drug in pregnancy methadone is a category B Methadone is considered an appropriate treatment for pregnant patients, but if it is unavailable, buprenorphine can be utilized after discussing the risks and benefits of therapy with the patient Buprenorphine is expressed in breast milk, but there is a low gastrointestinal uptake. As a result, it is unclear if nursing can be continued in patients on buprenorphine therapy The major disadvantage of detoxification is that a high proportion of women return to illicit opioid use.

antegrade amnesia

can occur with therapeutic doses of benzodiazepines

Leading substance of abuse for adolescents entering substance abuse treatment

cannabis

III.5

clinically managed high intensity residential service, consisting of 24 hour care with trained counselors to stabilize multidimensional imminent danger and prepare for outpatient treatment patient treated at this level should be able to tolerate and utilize the full active milieu or therapeutic community

III.2-D

clinically managed residential detoxification and it is appropriate for patients expected to experience moderate withdrawal

CBT (Cognitive Behavioral Therapy) best treatment for both

co-existing anxiety and substance abuse disorders

PER1

cocaine addiction changes in circadian rhythm in cocaine abusers

National Quality Forum (NQF)

congressionally chartered to establish and disseminate definitions and standards for the health care system

energy drinks

contain somewhere between 100-500 mg caffeine

Acute intoxication

decrease in REM sleep and sleep disruption during second half of sleep

Smoking _____________________ the efficacy of many psychiatric medications.

decreases Haloperidol, fluphenazine, thiothixine, olanzapine and clozapine are metabolized more rapidly in smokers. Cigarette delivered tar, carcinogens and other by-products of tobacco accelerate of metabolism and clearance of these drugs; therefore higher doses are required for the same clinical efficacy as in non-smokers.

> 7.5 mg

dosage of marijuana = severe effects such as delirium, altered mental status, myoclonic jerking, and other concerning neurological symptoms, panic

Epidemiological studies of adults also show that anxiety, mood, and antisocial personality disorders are more strongly associated with

drug dependence than with drug abuse.

Endogenous opioid peptides include the families of

dynorphin, endorphin, and enkephalin

The endogenous opioids

dynorphins, enkephalins, endorphins, endomorphins and nociceptin

CYP4503A4

enzyme that metabolizes methadone

ALDH1A1

epigenetic changes that occur in patients who suffer EARLY CHILDHOOD ADVERSITY leading to alcohol abuse eventually

MATCH

examined the effectiveness of three individual treatments after identification of 11 baseline patient characteristics among study subjects Treatments examined: twelve-step facilitation, motivational enhancement therapy, and cognitive-behavioral relapse prevention. Only one of the matching hypotheses was supported by data from the study but several secondary matching factors were identified. Motivational enhancement therapy appeared to be effective for angry patients compared to other treatments, and twelve-step facilitation was found to be effective for patients with other substance abusers in their social network.

pantoprazole

false positive for cannabinoids

Selegiline

false positive for methamphetamines

With laboratory tests for cannabis use

false-negative results tend to be more common than false-positive results

Rehabilitation Act of 1973

federal law that forbids any government agency that receives federal funding from engaging in discrimination of any kind

2 cents

for every dollar that government spends on addiction and risky substance use, this is how many cents actually go to prevention and treatment

Hashish Oil > Sinsemilla > Hashish > Smoked Cannabis

forms of cannabis from highest to lowest in terms of potency as determined by percent content of ∆9-tetrahydrocannabinol

JWH-018, an ingredient of "K2" and "Spice"

full AGONIST at CB1 receptors THC is a partial agonist at CB1

CRN1

gene encodes the human endocannabinoid receptor 1 (CB1) CB1 is the putative binding site for Δ9-tetrahydrocannabinol most frequently studied of CRN1 polymorphisms is the AAT repeat in the 3' untranslated region of the gene, a variable number of tandem repeats with unknown functional consequence. greater than 15 repeats may be at increased risk for addiction to marijuana and other illicit drugs.

AUTS2

gene involved in differences in human prefrontal cortex that result in a myriad of different behaviors displayed in patients who abuse alcohol

CAMK4

gene involved in higher susceptibility to cocaine addiction

CYP2A6

gene involved in smoking relapse.

CRN1

gene that encodes the human endocannabinoid receptor 1 (CB1) which is the putative binding site for Δ9-tetrahydrocannabinol

OPRM1 gene is linked to less reduction of heavy drinking when prescribed naltrexone. Which of the following racial groups is most commonly affected by this gene mutation?

gene, WHEN MUTATED, is linked to less reduction of heavy drinking when prescribed naltrexone most common point mutation in a mutated OPRM1 leading to increased risk of alcohol relapse is ARGININE---> ASPARTIC ACID second most common point mutation is ALANINE ---> VALINE The mutation is MOST common in Chinese and Japanese The mutation LEAST common in African AmericanS

Gabapentin (Neurontin)

has been found to significantly reduce marijuana withdrawal symptoms and marijuana use

Brain-derived neurotrophic factor (BDNF)

has been shown to play a role in the synaptic remodeling associated with addictive processes thought to be an important molecule in the incubation of craving phenomenon and synaptic remodeling in the nucleus accumbens has been shown to play a role in the plasticity associated with cocaine craving. studies have suggested that increased levels of BDNF observed in the nucleus accumbens during the incubation of craving may occur as the result of heightened AMPA-receptor activity. it has been shown that alcohol consumption increases BDNF levels in the dorsal striatum in rodents incubation of craving phenomenon is thought to involve learning and memory and synaptic remodeling in the nucleus accumbens, amygdala, and hippocampus.

naloxone and naltrexone have

have both been proven to be successful in treating depersonalization.

Anticonvulsants

have shown some efficacy for the treatment of alcohol use disorder through their actions as glutamate antagonists and GABA agonists

Cocaine

hypertensive nephrosclerosis

CBT "functional analysis."

includes thoughts, feelings, antecedents and consequences of substance use may provide information about the role substances serve in a person's life may provide information about why a person continues to have substance use lapses after they have been in treatment for a while may uncover reasons for substance use which have led an individual to choose to use cocaine, e.g., anxiety about social situations

Drug tolerance

increased metabolism of a drug after repeated administrations

PCP (angel dust)

initially developed as an IV anesthetic No longer legal in the US, Schedule 1 Risk of seizures or death rotary nystagmus check serial CPKs because rhabdomyolysis a risk

Behavior modification

involves changing behaviors for reducing pain perception.

role of Forensic expert

is limited yet thoughtful: to produce an opinion for the question asked render an opinion that is as unbiased and objective as possible

The Controlled Substances Act (CSA)

is the federal U.S. drug policy under which the manufacture, importation, possession, use and distribution of certain substances is regulated

The most common course of adult alcohol dependence is that:

it resolves over a period of 3-4 years

Salvia Divinorum

kappa opiate receptor agonist hallucinations, visual distortions, perceptual disturbances, anxiety, confusion, and dysphoria, without any psychomotor agitation or hostility synesthesia (i.e., hearing colors or smelling sounds) "out of body experience" can last as long as 24 hours.

CIWA-Ar score

less than 8 to 10: can be treated as outpatients and may not require medication 8 to 15: outpatients OK but may require medication for symptomatic treatment greater than 15: inpatient

Acamprosate (Campral)

levels increase when given with naltrexone

Physician illegal drug use

lifetime prevalence rate of substance use disorders = 8-15% = comparable to the general population highest rates: psychiatry, emergency medicine and anesthesiology most frequently abused substance = alcohol = same as general population most common illegal drug = cannabis = same as the general population.

Fragile X syndrome

long, thin face with prominent ears prominent foreheads facial asymmetry a head circumference higher than the 50th percentile prominent jaw Macroorchidism

Health Insurance Portability and Accountability Act (HIPAA)

mandates the establishment of standards for the privacy of "individually identifiable health information."

Liver disease

mechanism that causes renal disease in alcohol use disorder

carbon disulfide and acetone

metabolites of disulfiram tested for in breathalyzer to monitor compliance

Lorazepam (Ativan)

metabolized to glucuronide

CYP2A6

metabolizes nicotine

OPRD1

methadone WORKS

OPRD1

methadone maintenance WORKS

2-3 hours

methamphetamine: when ingested, achieve peak plasma concentrations approximately ____________________________ after ingestion.

Selective G-protein-coupled opioid receptor μ-agonist drugs

morphine, heroin, most clinically-used opioid drugs analgesia + euphoria + respiratory depression + antidiuretic effects + emesis

Inhalants

most Common Ave., West decreases with age Highly lipophilic: readily crosses blood-brain barrier

Δ9-tetrahydrocannabinol (∆9-THC)

most abundant psychoactive compound in marijuana rapidly converted to the metabolite 11-hydroxy-∆9-tetrahydrocannabinol 11-hydroxy-∆9-tetrahydrocannabinol is the cannabis chemical that is most active in the central nervous system

altered perception of TIME

most common subjective effect of MDMA ("ecstasy")

GABA and norepinephrine

neurotransmitters or neurotransmitter combinations involved in alcohol withdrawal

24 to 48 hours

nicotine withdrawal symptoms peak (i.e., reach maximum severity)

polysubstance dependence

no longer used as a clinical diagnosis in DSM-V

sustained recovery

no symptoms in past year

ALDH5A1

non-responsive patients who receive maintenance therapy for opioid addiction

COWS

objective assessment (heart rate, pupil size, sweating, etc.) of withdrawal from opiates Nurses are regularly trained to administer COWS scores: 5-12 = Mild 13-24 = Moderate 25-36 = Moderately Severe More than 36 = Severe Withdrawal COWS does not ask patients about cravings

Withdrawal seizures in alcohol withdrawal

occur in approximately 10% of patients usually within 24 to 48 hours after last consumption or significant reduction When untreated, seizures progress to delirium tremens in approximately one-third of patients

salvia

onset: 1 min duration: < 30 mins

LSD (lysergic acid diethylamide)

onset: 30-60 mins peak: 2-4 hrs duration: 8-12 hrs

Alcohol use disorders are associated with an increased risk of:

pancreatic disease including insufficiency. Osteonecrosis of the bone

predictor of drinking and increased risk for development of alcohol abuse and dependence

people who smoke at an early age

antisocial personality disorder

personality disorder most commonly is present in patients with substance use disorders

The mesolimbic pathway and a specific set of the pathway's output neurons (i.e., D1-type medium spiny neurons within the nucleus accumbens)

play a central role in the neurobiology of addiction also implicated in schizophrenia and depression Addiction, schizophrenia, and depression all involve distinct structural changes within the mesolimbic pathway.

benzodiazepines

prescribed to approximately 30% of psychiatric patients greatest use among patients with affective disorders, long duration of mental illness, and high use of psychiatric services All benzodiazepines work by binding to the GABA-A receptor, resulting in a conformational change with a greater affinity for GABA Benzos bind to the receptor site, hyper-polarize the membrane which increases frequency of opening of the chloride ion channel. benzodiazepines potentiates the inhibitory effects of available GABA, resulting in sedation and anxiolytic effects metabolized in the liver by cytochrome P450 3A4 oxidation and glucuronide conjugation, with the exception of lorazepam, oxazepam, and temazepam, which are metabolized only by conjugation

Tobacco Cigarette > Spray > Inhaler > Lozenge > Gum > Patch

ranking of the onset of peak nicotine level for the following substances, from fastest to slowest

Diazepam (Valium)

rapidly absorbed lipophilic benzodiazepine metabolized to oxazepam

Benzodiazepines

rarely fatal in overdose

alcohol metabolism

relatively constant, regardless of blood alcohol level mostly absorbed in jejunum occurs in the liver by alcohol dehydrogenase (ADH) and mixed function oxidase enzymes, such as cytochrome P450 2E1 (CYP2E1) CYP2E1 levels increase in chronic drinking so that the drinker is able to metabolize more alcohol per hour ADH coverts alcohol to acetaldehyde acetaldehyde dehydrogenase (ADLH) converts acetaldehyde to acetate ADH metabolizes at a constant level = zero-order kinetics Alcohol metabolism is proportional to body weight.

ALANINE ---> VALINE

second most commonly found mutation in OPRM1 gene that leads to increased risk of alcohol relapse

Clonidine

second-line prescription agent that can be used for smoking cessation

Insomnia including somnambulism

severe side effects to high-dose baclofen

CYP2A6

smoking relapse

Spice

street name for synthetic cannabis

Family-based prevention programs

strengthen protective factors among young children teach parents better family communication skills, appropriate discipline styles, firm and consistent rule enforcement, and other family management approaches

Marijuana Use Disorder

substance use disorder that has the highest comorbidity with anxiety disorders based on the NESARC survey (National Epidemiological Survey on Alcohol and Related Conditions)

Alcohol, benzodiazepines, or barbiturates

substances that could cause a patient presenting to the emergency department with slurred speech, incoordination, and nystagmus, who wanders if left unattended and has difficulty locating his room when told to return to it

short-acting nicotine replacements

supposed to be used for 3 MONTHS as part of a smoking-cessation program

30 minutes

the approximate time the euphoric effects of cannabis peak after first exposure

Bioavailability

the fraction of unchanged drug that reaches the systemic circulation

Dialectical behavior therapy (DBT)

the gold standard for the treatment of co-occurring borderline this personality disorder and substance use disorders

urination

the largest amount of methamphetamine eliminated from the body by this mechanism

how many people with SUDs who enter sustained recovery participated in treatment

the majority

Generalized tonic-clonic seizure

the most common type of seizure induced by substance use

GABA (gamma-aminobutyric acid)

the primary inhibitory neurotransmitter in the central nervous system.

Absorption

the process of drug molecule movement from the site of drug delivery to the target site of action

elimination

the removal of drug by metabolism or excretion

four (4)

the steps of Alcoholics Anonymous which use the word "God" in them

reward circuitry involves connections between

the ventral tegmental area and the basal forebrain

social learning theory & CBT

theoretical constructs from which Motivational interviewing for treatment of substance use disorders is derived

DSM-5 diagnosis of cannabis withdrawal

three or more of the following signs and symptoms must develop within approximately 1 week after cessation of heavy, prolonged use: Irritability, anger, or aggression Nervousness or anxiety Sleep difficulty (ie, insomnia, disturbing dreams) Decreased appetite or weight loss Restlessness Depressed mood At least one of the following physical symptoms causing significant discomfort: abdominal pain shakiness/tremors sweating fever chills headache

transverse myelitis

uncommon effect of heroin abuse pain in the neck, back, or head feeling of a tight band around the chest or abdomen weakness, tingling, and numbness of the feet and legs Voiding difficulty can appear over hours to several days deficits can progress to complete transverse sensorimotor myelopathy, with paraplegia, loss of sensation below the lesion, urinary retention and fecal incontinence. Position and vibration sense may be spareD The treatment: corticosteroids

heroin

very long duration of 4-5 hours due to active metabolites more lipid soluble than other opioids, allowing to cross the blood-brain barrier easily to each dangerously high levels in the brain, which may cause mental status damage to the patient.

Pharmacodynamics

what the DRUG does to the BODY

most common point mutation involved in a mutated OPRM1 gene that leads to increased risk of alcohol relapse is arginine->aspartic acid. Alanine->Valine is the second most commonly found mutation.

when NOT mutated = greater reduction of heavy drinking when prescribed naltrexone When mutated = increased risk of alcohol relapse?

List the FOUR distinct developmental stages of drug use, according to the "gateway theory" developed by Kandle in 1982

1. Beer or wine consumption 2. Cigarette smoking or hard liquor consumption 3. Marijuana use 4. Other illicit drug use

Stages of chronic care management a substance use disorders

1. Early identification/intervention: use of verbal or electronic screening instruments, brief motivational interviewing, and office-based and off-site monitoring with consequences. 2. Stabilization: medications to manage withdrawal cravings, maintenance medications, brief motivational interviewing, and individual therapy 3. Clinical management/monitoring: maintenance medications, brief motivational interviewing, family and couples therapy, individual therapy, and monitoring with consequences 4. Personal management: maintenance medications, self-help groups and activities, and individual, family and couples therapy as needed.

AUDIT-C

1. How often did you have a drink containing alcohol in the past year? +0 Never +1 Monthly or less +2 Two to four times a mont +3 Two to three times per week +4 Four or more times a week 2. How many drinks containing alcohol did you have on a typical day when you were drinking in the past year? +0 1 or 2 drinks +1 3 or 4 +2 5 or 6 +3 7 to 9 +4 10 or more 3. How often did you have six or more drinks on one occasion in the past year? +0 Never +1 Less than monthly +2 Monthly +3 Weekly +4 Daily or almost daily Maximum score is 12 Scores 4+ in men identifies 86% to drink more than the recommended amount or have AUD Scores 3+ in women identifies 84% Who report hazardous drinking or with AUD

Testamentary capacity is comprised of three abilities:

1. Knowledge of the composition and value of one's estate. In some states this is referred to as "knowledge of one's bounty." 2. Knowledge of one's natural heirs or the "natural objects of one's bounty" 3. Knowledge regarding the nature of the testamentary act (i.e., knowing that the heirs will receive the bounty as the will is executed.)

The 12 traditions of Alcoholics Anonymous

1. Our common welfare should come first; personal recovery depends upon AA unity 2. For our group purpose there is but one ultimate authority - - a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern 3. The only requirement for AA membership is a desire to stop drinking 4. Each group should be autonomous except in matters affecting the other groups or AA as a whole 5. Each group has but one primary purpose - - to carry its message to the alcoholic who still suffers 6. An AA group ought never endorse, finance, or lend the AA name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose 7. Every AA group I want to be fully self-supporting, declining outside contributions 8. Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers 9. AA, as such, ought never be organized; but we may create special service boards or committees directly responsible to those they serve 10. Alcoholics Anonymous has no opinion on outside issues; hence the AA name ought never be drawn into public controversy 11. Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films 12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities

The Dimension 4 assessment, or readiness for change assessment (ASAM)

1. PRECONTEMPLATION - not yet considering possibility of change, active resistance to change, seldom appear for change without coercion 2. CONTEMPLATION - ambivalent, undecided, vacillating between whether the need exists for change or not, wants to change but also resists the changes needed 3. PREPARATION - takes client from decisions made in contemplation to the steps needed to change. Increasing confidence in the decisions needed for change 4. ACTION - specific actions intended to bring about change, overt modification of behavior and environment. Support/encouragement is essential at this stage to prevent dropout & regression 5. MAINTENANCE - Sustaining the changes begun. Consolidate gains, learn alternative coping & problem-solving strategies, recognize emotional triggers for relapse 6. RELAPSE & RECYCLING - Possible but not inevitable setbacks. AVOID becoming stuck and learn from mistakes to determine new cycle of changes 7. TERMINATION - Ultimate stage for all changers, person exits cycle of change without fear of relapse. Some problems terminated while others are kept in remission through ongoing maintenance efforts

The two main concepts that illustrate the therapeutic approach of role models in a therapeutic community (TC)

1. Role models "act as if." The role model behaves as the person he or she should be, rather than as the person he or she has been. Despite resistances, perceptions, or feelings to the contrary, the role model engages in the expected behaviors and consistently maintains the attitudes and values of the community. "Acting as if" is not merely an exercise in conformity; it is an essential mechanism for more complete psychological change 2. Role models display responsible concern. This concept is closely akin to the notion of being one's brother's or sister's keeper.

The 12 steps of Alcoholics Anonymous

1. We admitted we were powerless over alcohol - - that our lives had become unmanageable 2. Came to believe that a Power greater than ourselves could restore us to sanity 3. Made a decision to turn our will and our lives over to the care of God as we understood Him 4. Made a searching and fearless moral inventory of ourselves 5. Admitted to God, to ourselves, and to another human being, the exact nature of our wrongs 6. Were entirely ready to have God remove all these defects of character 7. Humbly asked Him to remove our shortcomings 8. Made a list of all persons we had harmed, and became willing to make amends to them all 9. Made direct amends to such people wherever possible, except winter do so would injure them or others 10. Continued to take personal inventory and when we were wrong promptly admitted it 11. Sought through prayer and meditation to improve our conscious contact with God, as we are understood Him, praying only for knowledge of His will for us and the power to carry that out 12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs

3 most influential affecting successful treatment of substance use disorders in adolescents

1. longer duration of treatment 2. readiness to change substance abuse behavior 3. family involvement

approximately how many Americans use cocaine every month?

1.6 million

How clinical effects of alcohol correlate with blood alcohol levels

100-150 mg% = obvious signs of intoxication 150-200 mg% = very drowsy or even sleeping 300-399 mg% = stage I anesthesia = severe dysarthria and amnesia 400-600 mg% = alcoholic coma 600 mg% = fatal level

The Minnesota Model

12 step philosophy and many counselors who are in recovery themselves Fixed length of stay commonly four weeks Based on the principles of Alcoholics Anonymous and narcotics anonymous Does NOT specifically use CBT or relapse prevention techniques Does NOT employ a medical model or significantly involved physicians It is NOT an algorithm for detoxification It is NOT a contingency management program

Opioid Use Disorder for adults in the United States

12-month prevalence rate for all severities = 0.37% may underestimate because does not include incarcerated population males 0.49% females 0.26% male-to-female ratio typically holding at 1.5 : 1 for prescription opioids and 3 : 1 for heroin Prevalence rates in adult US population subgroups are as follows: 1. Native Americans 1.25% 2. Hispanics 0.39% 3. White/Caucasians 0.38% 4. Asian Americans and Pacific Islanders 0.35% 5. African Americans 0.18%

Six Sermons on the Nature, Occasion, Signs, and Remedy of Intemperance

1827 publication by Reverend Lyman Beecher exerted its influence on the emerging concept of addiction. Bridging the gap between moral and medical models, Beecher described the intemperate as being "addicted to the sin" and suffering from an "insatiable desire for drink." Beecher provided two other contributions to this developing concept. First, he described the early warning signs of addiction. Second, he challenged physicians who had tried to get their patients to moderate their drinking by switching from distilled alcohol to fermented drinks such as wine or beer. This marked the call for complete abstinence as a personal and social strategy for the resolution of alcohol problems

Methomania: A Treatise on Alcoholic Poisoning

1860's Dr. Albert Day, an American physician discussed the medical concept of intoxication

SOCRATES =Stages of Change Readiness and Treatment Eagerness Scale

19-item short form of the self-report instrument assesses motivation to change drinking behavior based on the transtheoretical model of change assesses patient's level of recognition of a problem, ambivalence, or uncertainty about changing and whether the patient is taking steps to change employed to monitor motivational level and predict compliance with and outcome of treatment

ASAM dimensions

1: Acute Intoxication and/or Withdrawal Potential Dimension 2: Biomedical Conditions / Complications Dimension 3: Emotional, Behavioral or Cognitive Conditions / Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use or Continued Problem Potential Dimension 6: Recovery/Living Environment

Six dimensions of ASAM placement criteria

1: Acute Intoxication and/or Withdrawal Potential Dimension 2: Biomedical Conditions / Complications Dimension 3: Emotional, Behavioral or Cognitive Conditions / Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use or Continued Problem Potential Dimension 6: Recovery/Living Environment

Percentage of veterans who served in Afghanistan and Iraq who have both PTSD and SUDs

20%

Level III

24-hour care with trained counselors to stabilize multidimensional imminent danger and prepare for outpatient treatment

In patients who abuse cocaine, approximately what percent of patients who abuse cocaine end up developing cocaine dependence?

25%

The 2011 National Survey on Drug Use and Health found that __________% of the U.S. population reported current use of tobacco products, and among U.S. adults, ______________ % were dependent on tobacco

26.5, 12.8

percent of Americans report BINGE drinking in past month on average

27%

In twins who both abuse cannabis the concordance rates, respectively, for monozygotic male twins vs. dizygotic male twins

28%, 9%

Maximum first dose of methadone in a methadone maintenance treatment program, by law is

30 mg

Chemicals and carcinogens found in smoking tobacco

4000 chemicals in addition to nicotine 70 carcinogens

How many subunits combine in different ways to form GABA-A channels in the brain

5 Minimal requirement to produce a gabba gated ion channel is both alpha and beta subunits Most common type in the brain is a pentamer comprising two α's' two β's and a δ

Fagerstrom Test for Nicotine Dependence (FTND)

6 simple questions: 1. How soon after you wake up do you smoke your first cigarette? 2. Do you find it difficult to refrain from smoking in places where it is forbidden? 3. Which cigarette would you hate most to give up? 4. How many cigarettes per day do you smoke? 5. Do you smoke more frequently during the first hours after awakening than during the rest of the day? 6. Do you smoke even if you are so ill that you are in bed most of the day? consistent and strong predictive correlation between FTBD scores and smoking FTND level of dependence on nicotine: 0-2 Very low dependence 3-4 Low dependence 5 Medium dependence 6-7 High dependence 8-10 Very high dependence

In 2013 US population aged 12 years and older with some form of alcohol abuse or dependence (now called alcohol use disorder per the DSM-5):

6.6%

In the 2011 survey conducted by annual National Survey on Drug Use and Health, what was the prevalence of alcohol abuse?

6.9% of men and 2.6% of women

National Epidemiologic Survey on Alcohol and Related Conditions from 2002, the lifetime prevalence of drug abuse and dependence

7.7% of men and 2.6% of women

National Epidemiologic Survey on Alcohol and Related Conditions from 2002, what was the lifetime prevalence of drug abuse and dependence

7.7% of men and 2.6% of women

Nicotine metabolism

70 and 80% is converted to cotinine in a 2 step process involving CYP2A6 Menthol inhibits CYP2A6 and so decreases nicotine metabolism In those over 65, total nicotine clearance is reduced by 23% Women metabolize nicotine more rapidly than men: 13% faster those using oral contraceptives have a 28% increase Pregnancy 60% increase clearance Rifampin, dexamethasone, and phenobarbital induce CP2A6, resulting in increased nicotine clearance Methoxsalen, a phototoxic substance used in the management of psoriasis as part of oral PUVA (psoralen plus ultraviolet A) photo chemotherapy, decreases nicotine clearance through inhibition of CYP2A6

Percentage of people with alcohol or other drug-use-disorders who do not seek professional treatment

75 to 90% This has led some epidemiologists to label alcohol and drug abuse disorders as self-limiting Moos & Finney christened this way of thinking as, the "epidemiologist's illusion"

Smokers

75% wants to stop 30% tries to stop each year 3% succeeds unaided > 50% resume smoking within days or weeks after hospitalization for MI or COPD or larygectomies

Alcohol-related deaths annually in USA

88,000

Correct: E 12 month prevalence rate of cannabis dependence in US patients ages 21-26 is greater than 9%.

> 9%

hookah smoking delivers ____________________ nicotine than traditional cigarettes

>50% more

Compare National Survey on Drug Use and Health (NSDUH) and the Monitoring the Future Study (MTF)

Both reveal changes in the epidemiology of illicit drug use over the past 30 years Both show an escalation of drug use in the United States in the 1970's Both show a relative peak around 1987, but the trend has leveled off and in some cases, drug use and drug use disorders have declined Both show similar trends in drug use over the past decades discrepancies between the two surveys. MTF: only youth attending school in grades 8, 10, or 12 MTF: higher estimate of tobacco, alcohol, and illicit drug use among youth compared to the NSDUH NSDUH: household survey MTS: conducted in schools MTS: descriptive and analytic study MTS: relationship between drug use and beliefs about drugs, such as beliefs about the harmfulness of marijuana MTS: inverse relationship between beliefs about harm associated with marijuana use and prevalence of its use

Which of the following is an accurate reflection of currently available evidence of the relationship between psychiatric disorders and drug disorders? A. Antisocial personality disorders are more strongly associated with drug abuse than drug dependence. B. The relationship between conduct problems in childhood and risk of substance abuse in adulthood is independent of the number of conduct problems diagnosed. C. The odds ratio between lifetime psychiatric and drug use disorders is higher for drug dependence than drug abuse for any mood disorder. D. Although epidemiological studies reveal associations between psychiatric and drug disorders, this association does not appear to be etiologically meaningful. E. Current and past smoking is associated with onset of substance use disorders.

C

gene involved with smoking cessation and interaction with pharmacotherapy to stop smoking addiction

CHRNA5

Which of the following diagnoses carries the greatest risk of violence? A. Schizophrenia B. Bipolar disorder C. Alcohol use disorder D. Co-occurring alcohol and cocaine use disorders E. Co-occurring schizophrenia and cocaine intoxication

CORRECT: E. Co-occurring schizophrenia and cocaine intoxication Violence is usually not associated with mental disorders alone (only about 4%) However mental illness plus substance-abuse = increase in violence

gene involved in smoking relapse

CYP2A6

dopaminergic enhancement

Caffeine intoxication

21, 1 to 5

Cannabinoids can be detected in the urine for as many as ______ days after use in persons chronically using marijuana because these lipid-soluble metabolites are slowly released from fat cells into the blood; however, _________ days is the normal urine-positive period. Urine immunoassays correlate with prior exposure, not with the amount used or degree of clinical effect.

DSM-5 versus previous editions

Cannabis with drawl is now fully recognize syndrome Abuse and dependence have been combined into a single disorder of graded severity Substance related legal problems symptom has been removed because it was of such high severity that it had a little clinical utility Craving is now recognized as a key clinical feature of substance use disorders

risk factors for sedative abuse:

Caucasian female unemployed Alcohol Abuse ΝOT LACK OF EDUCATION . . . A patient's education status has little to no bearing on his or her chances of abusing sedatives.

Addiction to opioids

Complex of maladaptive behaviors Not just a collection of pharmacologic phenomena: tolerance, dependence, dose escalation Combination of: ADVERSE CONSEQUENCES of the use of drugs, LOSS OF CONTROL of use, PREOCCUPATION with drug use

Therapeutic uses of cannabis

Controlled trials show that smoked cannabis significantly reduces neuropathic pain in HIV-positive patients Control of movement disorders (over 90% of MS patients report improvement after taking cannabis) Anticonvulsant Improvement of appetite and AIDS patients Glaucoma treatment Treatment of chronic pain Anti-emesis

Which of the following brain areas or systems is most directly implicated in emotional dysregulation during the withdrawl/negative affect stage of addictive behavior? A. Lateral habenula B. Mesolimbic dopamine system C. Hypothalamic-pituitary-adrenal (HPA) axis D. Prefrontal cortex A. Insula

Correct answer is C. HPA axis The stress response system, including the HPA axis has been implicated as playing a central role in the emotional dysregulation that is characteristic of the withdrawal, negative affect stage of addictive behavior The lateral habenula signals the absence of expected rewards but does not play a role in drug withdrawal/negative affect The mesolimbic dopamine system is implicated in the binge/intoxication stage, not in the withdrawal/negative affect stage The prefrontal cortex plays a role in control over drug seeking behavior during the preoccupation/anticipation stage The insula also plays a role in the preoccupation/anticipation stage

Which specific psychological mechanism is one of the most important and well studied causal mechanisms explaining substance use behavior change among 12 step program members? A. Self efficacy B. Acquiring a sponsor C. Spirituality D. Powerlessness over alcohol E. Motivation for drinking reduction

Correct is A. Self efficacy, or confidence to remain abstinent

Which of the following hallucinogens or club drugs is considered to be a drug dependence/addiction? A. LSD B. Psilocybin C. MDMA D. Ketamine E. Mescaline

Correct is D. Ketamine PCP is also considered addictive

Which of the following is a proven effect of brief intervention for patients with alcohol use? A. Reductions in motor vehicle crashes B. Reduction in mortality C. Reduction in emergency room utilization D. Reduction in risky drinking by 10% at one year E. Reduction in risk drinking by 10 drinks per week

Correct is D. Reduction in risky drinking by 10% at one year The effect of BI is to decrease risky drinking by 10%to 12% at one year and by about three drinks per week

Which of the following patients has a substance-induced mental disorder? A. A 16-year-old boy who begin drinking to cope with social anxiety B. A 31-year-old man who developed auditory hallucinations two years after cessation of cocaine use C. A 30-year-old woman who complains of depressed mood after two years of near daily marijuana use D. A 77-year-old man with a history of daily alcohol use who experiences disorientation and visual hallucinations three days after his last drink E. A 21-year-old woman who developed depressed mood and suicidal thoughts one week after using cocaine for the first time

Correct is E. A 21-year-old woman who developed depressed mood and suicidal thoughts one week after using cocaine for the first time A diagnosis of a substance-induced of mental disorder is made when symptoms meeting the full criteria for a mental disorder develop during or within ONE MONTH of intoxication with or withdrawal from a substance that is capable of causing the mental disorder

For which of the following cognitive enhancers, compare with placebo, have studies demonstrated improvements in sustained attention, reduction in cocaine positive urine specimens, and fewer self-reports of cocaine use? A. Varenicline B. Modafinil C. Amphetamines D. Glutamate agonists E. Galantamine

Correct is E. Galantamine Varenicline = partial nicotinic acetylcholinereceptor agonist Modafinil = cholinesterase inhibitor

Which of the following behavioral phenomena is thought to be due to elevated brain reward thresholds during acute drug abstinence? A. Increased craving B. Decreased tolerance C. Decreased control over drug seeking D. Increased negative motivational/affective state during acute abstinence E. Decreased arousal

Correct is item D. Increased negative motivational/affective state during acute abstinence Elevated brain reward threshold refers to the greater level of stimulation required to elicit dopamine in reward related regions such as the nucleus accumbens Acute abstinence raises this threshold which causes a negative motivational/affective state characterized by dysphoria, anxiety, irritability, and anhedonia

Developmental patterns and which brain regions lead to particular vulnerability for substance use disorders during adolescence? A. Curvilinear development of the striatum B. Linear development of the striatum C. Curvilinear development of the prefrontal cortex D. Linear development of the sensory and motor cortices E. Neuronal pruning in the sensory and motor cortices

Correct: A. Curvilinear development of the striatum Explanation: striatal development associated with reactivity to motivational stimuli occurs in curvilinear fashion not linear, whereas prefrontal development which is associated with cognitive control occurs in a linear fashion over the course of adolescence

What has been a consistent research finding among therapeutic community (TC) participants? A. Longer retention and treatment is correlated with better post treatment outcomes B. Treatment completion shows no improvement in employment C. Participation in a TC does not alter criminal activity D. TCs are an effective and cost-effective treatment for all substance abusers E. Enrollment alone in a TC is correlated with improved psychosocial functioning

Correct: A. Longer retention and treatment is correlated with better post treatment outcomes TCs Studies substantiate improvement in drug use, criminality, and employment TCs are cost-effective for some groups but not all

Which strategy has been shown to be most effective in reducing alcohol and drug consumption in teens? A. Enhancing publc advisory campaigns B. Increasing cost C. Intensify legal consequences D. Mandating school-based educational programs E Implementing self-esteem building programs

Correct: B. Increasing cost

Which of the following best describes the position taken by the Central Council of AA regarding individuals who are taking physician prescribed treatment and medications for substance dependence? A. Individuals who are taking naltrexone but not methadone or buprenorphine are permitted to attend and speak freely at all AA meetings B. Use a physician prescribed treatment medications is permitted C. Individuals taking physician prescribed treatment medications are not permitted to attend any AA meetings D. Individuals taking any physician prescribed treatment medications are permitted to attend and speak freely at all AA meetings E. the Central Council of AA has no position on the issue

Correct: B. Use a physician prescribed treatment medications is permitted Despite this many and perhaps most of the AA and NA groups do not permit individuals who are taking methadone or buprenorphine or at times naltrexone to speak at meetings. They are invited to stay but cannot speak until they stop taking these medications

What kind of neuron tonically inhibits dopaminergic neurons in the ventral take mental area (VTA) and is of main importance in opiate diction? A. Dopaminergic B. γ-aminobutyric acid (GABA)-ergic C. Cholinergic D. Noradrenergic E. Serotonergic

Correct: B. γ-aminobutyric acid (GABA)-ergic

In patients who abuse alcohol, which of the following risk factors is NOT commonly associated with alcohol use? A. Peer pressure from friends B. Being neurotic C. Being introverted D. Living in a stressful environment E. Having a cognitive disorder

Correct: C Extroverts not introverted, tend to be more at risk of alcohol abuse

Which of the following is NOT considered to be a strong risk factor for drug abuse in adolescents? A. Peer pressure B. Poor socioeconomic conditions C. Family history of drug use D. Aggressive behavior E. Poor self-control

Correct: C In multiple research studies conducted on the origins of drug abuse behaviors iand the common elements of effective prevention programs, all of the above are strong risk factors for drug abuse in adolescents EXCEPT for FAMILY HISTORY OF DRUG ABUSE Family history is MUCH MORE associated with increased chance of drug abuse in CHILDREN--once a child makes it into his teenage years, family history plays a much smaller role than any of the other above factors.

You admit a 25-year-old patient for opioid detoxification. He tells you he is using five bags of heroin intravenously per day. Approximately how many hours after his last heroin use would you expect withdrawal to begin? A. 3 to 5 hours B. 4 to 6 hours C. 8 to 12 hours D. 13 to 17 hours E. 36 to 72 hours

Correct: C. 8 to 12 hours Initial symptoms begin with intense craving and anxiety, also possibly with profound dysphoria and agitation. Symptoms then progress to perspiration, yawning, lacrimation, rhinorrhea, akathisia, and insomnia, and later to piloerection, hot and cold flashes, bone pain, myalgias, muscle spasms, nausea/vomiting/diarrhea, abdominal cramps, mydriasis, weight loss, exquisite tactile sensitivity, and a low-grade fever These symptoms peak 2 to 3 days after the last dose and should resolve by day five. Acute withdrawal from IV fentanyl begins 3 to 5 hours after use Acute withdrawal from the carotene begins 4 to 6 hours after last use Withdrawal from methadone begins 36 to 72 hours after last use

Which screening tool does the military use in pre-deployment physicals? A. PHQ-9 B. CES-D (Center for epidemiology studies - depression) C. DAST-10 D. AUDIT-C E. None of the above

Correct: C. AUDIT-C

Increased Alcoholics Anonymous (AA) attendance has been associated with reduction in which of the following negative affect states? A. Anger B. Resentment C. Depression D. Selfishness E. Narcissism

Correct: C. Depression

Which of the following racial/ethnic groups has the highest alcoholic liver Sarot sis mortality rates? A.White B. Black C. Hispanic D. Asian E. Pacific islander

Correct: C. Hispanic

Which cognitive 12-step mutual health organization mechanism of change is most strongly associate with her cover in adolescence? A. Enhanced self efficacy B. Identifying coping strategies C. Motivation for abstinence D. Increased religiosity E. Reduction in anger

Correct: C. Motivation for abstinence

Which treatment technique needs to be expanded in the military? A. 12 step meetings B. Inpatient treatment C. Outpatient treatment D. Mental health and SUD treatment E. Both b. and d.

Correct: C. Outpatient treatment

Which of the following screening tools for substance use disorders has low sensitivity in adolescents? A. SBIRT B. AUDIT C. POSIT (problem oriented screening instrument for teenagers) D. CRAFFT E. CAGE

Correct: CAGE

Which of the following patient characteristics is most important to consider when deciding whether to provide a standard or intensive referral to a 12 step group? A. Age B. Gender C. Spiritual believes D. Prior experience with 12 step groups E. Comorbid psychiatric diagnosis

Correct: D. Prior experience with 12 step groups

Which cognitive shift did patients who participated in 12 step therapy have in common with those who underwent cognitive behavioral therapy (CBT) according to the Finney, et al. (1998) study? A. Endorsement of the disease model of alcoholism B. Alcoholic identity C. Goal of abstinence D. Self efficacy to remain abstinent E. Increase in positive expectancies surrounding the use of substances

Correct: D. Self-efficacy to remain abstinent

Physiological dependence to benzodiazepines occurs in approximately half of patients who have received daily medications for which length of time? A. One a week B. Two weeks C. Greater than one month D. Greater than two months E. Greater than four months

Correct: E. Greater than four months Physiological dependence is almost never seen patients treated with them for less than two weeks

Which of the following school based, curriculum driven drug prevention programs has the highest level of success in reducing substance abuse? A. Life skills training (LST) B. Project ALERT C. Take charge of Your Life (TDYL) D. Hutchinson smoking prevention program (HSPP) E. Positive action (PA)

Correct: E. Positive action (PA)

Which nicotine replacement therapy has the highest abuse liability? A. transdermal patch B. gum C. lozenge D. Inhaler E. nasal spray

Correct: E. nasal spray The abuse potential is still much less than smoking tobacco cigarettes

According to Project MATCH, how did rates of abstinence at 12 months follow up differ among patients assigned to CBT, MET, and 12 step facilitation (TSF)? A. CBT clients reported the highest rate of abstinence B. MET client reported the highest rate of abstinence C. TSF clients report of the highest rate of abstinence D. TSF clients reported higher rates of abstinence relative to CBT clients but not to MET clients E. None of the groups reported a significant higher rate of abstinence relative to the other two groups

Correct: option C. TSF clients reported the highest rate of abstinence Project MATCH (2005)

Which medication ask exclusively as a non-selective opioid antagonist with no oh opioid agonist properties? A. Methadone B. Naloxone C. Naltrexone D. Buprenorphine E. Clonidine

Correct:B. Naloxone Naloxone is a non-selective opioid antagonist which competitively binds to μ- opiate receptors but has no intrinsic opioid agonist activity parentheses it binds with lower affinity to Kappa and delta opioid receptors) Naltrexone is also an antagonist of opioid receptors but is also a partial low efficacy agonist at the Kappa opioid receptor

Which of the following types of cognitive behavioral therapy promotes behaving in ways that promote valued goals instead of avoidance of discomfort? A. Assertiveness training B. Mindfulness C. Behavior modification D. Acceptance and commitment therapy E. Biofeedback/relaxation training

D. Acceptance and commitment therapy

Which is an endogenous ligand for the cannabinoid type I (CB1) receptor? A. Tetrahydrocannabinol (THC) B. Adenosine C. Nitric oxide D. Anandamide E. Glutamate

D. Anandamide

Which of the following medications has the most evidence supporting its effectiveness in treating patients with co-occurring schizophrenia and substance use disorders? A. Haloperidol B. Olanzapine C. Fluphenazine D. Clozapine E. Risperidone

D. Clozapine Typical antipsychotics like haloperidol and fluphenazine may worsen SUDs in patients with schizophrenia Second-generation antipsychotics quetiapine and aripiprazole show the next most consistency Olanzapine has mixed results

Drug cravings in cocaine abusers manifest with which of the following PET study patterns?

Decrease in metabolism in the prefrontal cortical regions in males.

Psychiatric comorbidities have been associated with substance use disorders. Which of the following statements accurately reflects current evidence? A. Fifty percent of adolescents with both ADHD and conduct disorder met criteria for substance use disorder at ten-year follow up B. There is evidence that treatment of childhood ADHD with stimulants results in increased vulnerability to drug abuse in later life. C. Persons with drug use disorders have a higher prevalence of anxiety disorders compared to mood disorders. D. A past history of panic disorder is associated with increased likelihood of current drug dependence. E. Onset of substance dependence was demonstrated to occur prior to onset of anxiety disorder among patients with generalized anxiety disorder.

E. Onset of substance dependence was demonstrated to occur prior to onset of anxiety disorder among patients with generalized anxiety disorder. Explanations: ADHD is highly associated with other psychiatric disorders ADHD affects 3% to 6% of school age children, with a male: female ration of 2-3:1 in the community population Because of the high comorbidity, there has been controversy about whether the disorder is primary or only occurs secondary to other psychiatric syndromes. Recent evidence shows many conditions occur concurrently with ADHD, necessitating modification of treatment response Disruptive behavior disorders appear to occur more commonly compared to other disorders associated with ADHD Both epidemiologic and clinical samples show concurrent ADHD and conduct disorders in 30% to 50% of cases Among persons with both ADHD and conduct disorders, over 70% met criteria for substance use disorder at ten year follow up treatment of children with ADHD with stimulants results in DECREASED vulnerability to drug abuse in later In the Teen Health 2000 survey, researchers found ADHD and attentional disorders by themselves did not seem to increase the relative risk of development of substance use disorders in adolescents. NCS & NESARC revealed a higher prevalence of mood disorders than anxiety disorders among patients with drug use disorders.

In patients who abuse sedatives ___________________ is most commonly co-abused with sedatives

ETOH NOT marijuana or opioids

transcutaneous electrical acupoint stimulation (TEAS)

Effective in detoxification and reducing opioid cravings shown in animal studies to accelerate the release of endorphins replaces the mechanical stimulation of acupuncture with electrical impulses opioid withdrawal symptoms significantly reduced most effective in those with a 5-year or more history of heroin abuse has been used successfully with buprenorphine: Significantly lower doses of buprenorphine are required when paired with TEAS

CYP2D6 (cytochrome p-450 isoenzyme 2D6)

Enzyme that converts MDMA, 3,4-methylenedioxymethamphetamine to HHMA

Primary enzyme that metabolizes cocaine in humans is

Esterase

ASAM PPC for adolescents

Excludes level III.3 treatment, which is not designated for adolescent populations

Acamprosate (Campral)

Excreted unmetabolized in the urine

Drug testing when used as a preventative strategy in the military has shown to be effective in reducing substance abuse: true or false

False

Red Ribbon, used by the military for SUD prevention, is supported by empirical evidence: true or false

False

Phenytoin (Dilantin)

False positive for barbiturates

Verapamil HCl

False positive for methadone

Ibuprofen

False positive for opiates

papaverine

False positive for opiates

False positives are more common than false negatives on on site drug testing: true or false

False. Surprisingly - - to me anyway - - the books say false negatives are more common than false negatives with on site drug testing--"on-site tests seldom produce false positives"

Kandel's gateway theory of adolescent drug use order of drugs used

First: beer or wine Second: cigarettes or hard liquor Third: marijuana Fourth: other illicit drug use

LOSS OF CONTROL

Frequent loss or theft reported Calls for early refills Prescriptions from multiple sources

CB1 receptors & CB2 receptors

G-protein-coupled receptors Function to inhibit adenylate cyclase CB1: CNS, especially basal ganglia, hippocampus, cerebellum, cerebral cortex, striatum CB2: peripheral immune cells, and in much smaller amounts in CNS

GABA receptors

GABA A receptors containing the α2 or α3 subunits mediate anxiety, exhibit phasic inhibition, and are located at the synaptic site GABA A receptors containing the α1 subunits mediate sleep GABA A receptors containing the α4 and α6 subunits are benzodiazepine-insensitive GABA B receptors are G protein-linked receptors that may be coupled with calcium or potassium channels

Genes associated with alcohol abuse

GABRG1 COMT Val158Met DRD2 Taq1A KIAA0040

co-occurring with AUD

GAD: 45% Depressive disorders: 30%-40% SAD: 20% OCD: NO INCREASED RISK PD, PD with agoraphobia: Slight increased risk

adolescents aged 12-17.

Gender differences are the least--almost no difference--in this age group

ADH4

Gene associated with increased risk for alcohol dependence

MDMA (ecstasy)

HYPONATREMIA SIADH

Advantage of hair testing over urine testing

Hair testing can distinguish among light, moderate, and heavy use of drugs and alcohol Hair testing window of detection from 70 to 90 days Urine testing window of detection from 1 to 3 days

Silvia divinorum

Hallucinogen Smoked or chewed Effects resolve in 10 to 15 minutes Possibly a treatment for chronic pain and cocaine drug dependence

Compared with abusers of prescription opioids, how do heroin abusers differ?

Heroin abusers have lower levels of chronic pain Heroin abusers have lower levels of benzodiazepine use Heroin abusers have lower levels of depression

Ranking for of racial/ethnic subgroups from highest to lowest with regards to their 12-month prevalence of alcohol use disorder fo 12- to 17-year-olds in the United States

Hispanics > Native Americans and Alaska Natives > Caucasians > African Americans > Asian Americans and Pacific Islanders

Antagonizing glutamate and suppressing alcohol-induced dopamine release

How TOPIRAMATE can reduce the number of heavy drinking days, increase the number of abstinent days, and reduce serum gamma-glutamyl transpeptidase (GGT) levels, which is an objective marker of alcohol abuse.

3 hours

How long the effects of inhaled marijuana occur after inhaling it

Cocaine effects on the brain

Increases in dopamine transporter in acutely abstinent cocaine abusers relative to control subjects Decreases in post synaptic dopamine receptors in cocaine users Decreases in dopamine D2 receptor binding in detoxified cocaine abusers relative to control subjects Reduced cerebral blood flow and cortical perfusion among chronic cocaine abusers Cognitive impairments especially in attention, working memory, and response inhibition functions

Nicotine interactions

Increases the clearance of heparin In combination with birth control pills, increases the risk of thrombosis. And thus stroke and MI in women Less sedation from benzodiazepines Less analgesic effects from some opioids Less blood pressure reduction and pulse rate reduction from beta blockers Impairs function of H2 blockers like ranitidine Slows the rate of absorption of subcutaneous insulin Induces the metabolism of theophylline, flecainide, propranolol, tacrine, caffeine, olanzapine, clozapine, haloperidol, imipramine, pentocine, estradiol

Methamphetamine

Induces intracellular dopamine-containing vesicles to dock with the cell membrane and leak dopamine into the synaptic cleft Neurotoxic: interferes with dopamine transport into the storage vesicles, thus increasing cytoplasmic concentration of dopamine which undergoes oxidation and produces oxidation products that are toxic to nerve terminals Its neurotoxicity is further accentuated by prolonged half-life & long action (>6 hours) Like cocaine it acts by blocking the reuptake of released dopamine in the synaptic clefts of the mesolimbic dopamine neurons UNLIKE cocaine it is carried into the dopaminergic neurons and exerts its primary action intracellularly So methamphetamine's actions: 1. Causes Dockit of the intracellular dopamine containing vesicles at the membrane, leading to the leakage of dopamine into the synaptic cleft 2. interferes with dopamine transport into the storage vesicles thus increasing the cytoplasmic concentration of dopamine which undergoes oxidation and produces oxidation products that are toxic to nerve terminals

The cannabis use use treatment (CYT) study, 2004

Largest, most methodologically rigorous multi site randomized controlled trial today to address outcomes of different treatment modalities on substance use disorders in teens n = 600 Five arms: 1. MET + CBT sessions x 3 2. MET + CBT sessions x 10 3. MET + CBT sessions x 10 + Family psychoeducational intervention 4. 12-week individual adolescent community reinforcement approach 5. 12 week multidimensional family therapy All 5 interventions produced significant reductions in cannabis use and negative consequences of use at three months In addition, option number 4, found reduction sustained at 12 month follow-up Multi dimensional family therapy was almost 3 times more expensive than any of the MET/CBT variations

Global Burden of Disease Project

Launched by WHO in 1990 ongoing worldwide study examined basic patterns of alcohol, tobacco, cannabis, and cocaine use in participating countries 2002 estimate: 91 million people were affected by alcohol use disorders and 15 million people were affected by drug use disorders. documented lifetime use of these substances, with a focus on young adults Onset of age of use, type of drug, and socioeconomic status were independently considered in the study. showed uneven distribution in global drug use that was unrelated to stringency of user-level illegal drug policies USA has stringent penalties for user-level illegal drug activity but has the highest level of both illegal and legal drug use in the world the Netherlands has a less criminally punitive approach to cannabis compared to the U.S., but levels of use are lower. The vast majority of respondents in the Americas, Europe, Japan, and New Zealand report lifetime use of alcohol The highest lifetime use of tobacco is in the United States, with 74% of the study respondents reporting use decline in sex differences in global drug use in recent cohorts Women are less likely overall to initiate drug use of all kinds in any given year of life, the gender effect is less pronounced in the 18-29 year old sample.

ASAM The levels of treatment

Level 0.5 Early Intervention Level I Outpatient Treatment Level II.1 Intensive Outpatient Level II.5 Partial Hospitalization Level III.1 Clinically Managed Low Intensity Residential Services Level III.3 Clinically Managed Medium Intensity Residential Treatment Level III.5 Clinically Managed High Intensity Residential Treatment Level III.7 Medically Monitored Intensive Inpatient Treatment Level IV Medically Managed Intensive Inpatient Treatment Sub-specifiers include: AOD -Alcohol or Drug treatment only DDC - Dual diagnosis capable (able to identify dual diagnosis problems. Capable of referral to outside provider if psychiatric comorbidity is identified as problematic in treatment DDE - Dual Diagnosis Enhanced capable on-site of managing patients who have addiction and current confounding psychiatric disorders These indicate the ability of the center to provide treatment necessary for a patient's psychiatric comorbidity. Other sub-specifiers indicate detoxification or concomitant medical treatment: D - Detoxification OMT -The program provides Opioid Maintenance Treatment BIO - Capable of managing complex medical comorbidity

3,4-methylenedioxymethamphetamine (Ecstasy)

MDMA side effects: tachycardia, headaches, nausea more pleasant effects: euphoria, improved sociability, and increased perception latter sensations are thought to result from increased synaptic serotonin and norepinephrine also thought to create pleasant sensations due to the release of the neuropeptide oxytocin

Ecstasy

N-methyl-3,4-methylenedioxy-amphetamine also: 3,4-methylenedioxymethamphetamine MDMA

pharmacological differences between naloxone and naltrexone

NALTREXONE has a greater affinity for kappa-opioid receptors NALTREXONE is longer acting and a 50 mg dose can block the pharmacologic effects of 25 mg of IV heroin for up to 24 hours Naloxone is short acting with a half-life of 30-80 minutes

50%, 90%

NESARC study (National Epidemiologic Survey on Alcohol and Related Disorders) approximately _____________of those with GAD had a lifetime comorbid substance use disorder, and of those with both GAD and substance use disorder, over ____________ had an alcohol use disorder.

MTF

NIDA of the NIH Adolescence, college students, adults through age 50 N=45,000 First look at bath salts in 2012 survey 8th-, 10th- and 12th-graders

Ethanol's mechanism of action

NMDA receptor antagonist

Ketamine

NMDA receptor antagonist FX begin in 10 minutes

marijuana use

NO difference in use among different races

Alcohol Use Disorder (AUD)

NO specific frequency or amount of alcohol that defines an alcohol use disorders based on impact drinking has on life AUD appropriate diagnosis for someone who drinks once a week but each time drinks to a blackout and behaves in socially unacceptable manners with significant repercussions Heavy drinking alone has

adults 18 years-of-age and older in the United States population, the following race/ethnic subgroups from highest to lowest in regards to their 12-month prevalence of Alcohol Use Disorder

Native Americans and Alaska Natives > White/Caucasians > Hispanics > African Americans > Asian Americans and Pacific Islanders

GHB (gamma hydroxybutyric acid)

Naturally-occurring neurotransmitter Precursor to GABA, glutamate, and glycine in certain brain areas Has been used as a general anesthetic Has been used as a treatment for cataplexy, narcolepsy, and alcoholism Date rape drug Elevates human growth hormone Agonist at GHB receptor = excitatory Agonist at oxytocin receptor Weak agonist at GABA-B receptor = inhibitory

Inhalants

Non-cardiac pulmonary edema, severe respiratory distress syndrome, barotrauma casing pneumomediastinum and asphyxia

PREOCCUPATION

Non-opioid interventions ignored Only opioids work for the pain Recurrent request for opioid increases Increased complaints of pain despite non-progression of painful condition

Epidemiological studies have revealed similar rates of drug use and drug use disorders in major race and ethnic groups in the United States but there is a significantly higher proportion of users who experience serious consequences among African American and Hispanic drug users NSDUH on is a household study do key populations are excluded, notably the homeless and the incarcerated Consideration of multiple studies yields a more complete understanding of drug use disorder in the United States. MTFS is school-based & it yielded higher estimates of tobacco, alcohol, and illicit drug use in youth when compared to the NSDUH MTFS is limited to youth in grades 8, 10, or 12 Marijuana abuse and dependence have increased among younger black and Hispanic people Epidemiologic studies have not documented a causal relationship between increasing use and dependence and increases in potency or availability, although this is a possible explanation for changes in prevalence of marijuana use seen in descriptive studies. the National Comorbidity Survey (NCS) shows that whites are more likely than African Americans or Hispanics to use drugs, but are less likely to experience development of persistent dependence.

Note there are some inconsistencies here

Nucleus Accumbens (NAcc)

Now called the ventral striatum

< 50%

Percentage of cases of drug diversion that are identified by observation of aberrant behavior.

69%

Percentage of cocaine seized in the United States in 2009 which contained levamisole, a veterinary anti-helminthic.

95%

Percentage of incarcerated persons which suffers from a substance use disorder

15%

Percentage of persons incarcerated in the federal system which needs substance use treatment, which suffers from a substance use disorder which is actually receiving treatment

Approximately one-fifth

Percentage of school-aged children and adults with prenatal alcohol exposure that meets diagnostic criteria for an anxiety disorder

5.7%

Percentage of the US population ages 12 and older who abused prescription medications in 2011 (NHSUD, 2012) 14.7 million people

60%

Percentage of time Borderline Personality Disorder (BPD) co-occurs with substance use disorders (SUDs)

79%

Percentage of youths reporting cannabis use who had a positive urine drug test

97%

Percentage of youths reporting no cannabis use who had a negative urine drug test

Detoxification

Probably the most common form of treatment for substance use disorders In reality, it is not a treatment at all The reason it is the most common form of treatment is because it is covered by most insurance programs and even state Medicaid programs

AA

Project MATCH found on 3-year follow up that those lacking a social network supportive of sobriety did better in 12-step Facilitation Therapy than either CBT or MET Multiple studies have found that regular AA attendance is predictive of reduced drinking more extensive involvement in AA including reaching out to other members, contact with a sponsor and working on the first four steps provided benefits over and above group attendance

Things that have not worked to reduce alcohol and drug use in teens

Public advisory campaigns Harsher legal consequences Educational programs to increase knowledge of consequences of drug use Self-esteem building and responsible decision making programs

National comorbidity study: adolescent supplement

Published 2010 Face-to-face interviews with over 10,000 US teens age 13 to 18 Prevalence of mental disorder: #1 = anxiety disorders (32%) #2 = behavior disorders (19%) #3 = mood disorders (14%) #4 = SUDs (11%)

NSDUH

SAMHSA annual 67,500 Primary source of information of the illegal use of alcohol, illicit drugs, tobacco in the United States for non-institutionalized persons age 12 and over

gene involved in amygdala activation and is linked to psychiatric issues in alcohol abuse

SLC6A4

Score > 20

Severe withdrawal on Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)

Serotonin type 2A (5HT2A) receptors

Site at which major action of Mescaline (the main psychoactive constituent in peyote cactus) occur

symptom of nicotine intoxication

Skeletal muscle relaxation

1 to 3 hours

Snorted or swallowed cocaine: approximate duration of action in the body

True

Studies have shown that programs whose length of stay was greater than 90 days showed the least improvement 7-8 months out

Lithium

Substance abuse is a predictor of poor response to this treatment

Interaction of smoking tobacco and medications

Tar and non-nicotine polycyclic aromatic hydrocarbons from tobacco smoke alter the metabolism of many psychiatric medications by increasing the rate of metabolic clearance of these medications and they can lower blood concentrations of the medications by up to 40% Olanzapine is rapidly metabolized by the cytochrome P450 system's CYP1A2 isoenzyme, so when a patient quits smoking, his/her Olanzapine blood levels will rise It's not the nicotine in the tobacco cigarettes but the non-nicotine chemicals that cause the problem

Washington Circle Group.

The Center for Substance Abuse Treatment has provided support to the Washington Circle Group to develop and measures that monitor the performance of health plans and public treatment systems six measures have been developed and evaluated in the field 1. treatment engagement 2. Identification: the percent of individuals among a group with an alcohol or drug disorder diagnosis 3. Continuity of care after assessment = percent with positive assessment for substance abuse and received another substance abuse service (other than detoxification or crisis care) within 14 days 4. Continuity of care after detoxification = percent which receives a detoxification service and received another substance abuse service (other than detoxification or crisis care) within 14 days of discharge from detoxification 5. Continuity of in varying residential situations = percent which has stay followed by another service (other than detoxification or crisis care) within 14 days after discharge. This measure can be calculated for three levels of residential care: short term, long term, and inpatient 6. Treatment initiation = percent which enters inpatient or outpatient care and completes another treatment session within 14 days

the National Survey on Drug Use and Health and the Monitoring the Future Study. One important difference between these studies

The Monitoring the Future Study documents the association between beliefs about drugs and use of drugs

major surveys both in the United States and internationally to determine the prevalence of drug and alcohol use disorders. Comparison of these studies may be limited by differing definitions of addiction, but there is evidence for several trends over time

The NLAES and NESARC reveal an increase in prevalence of alcohol abuse among all racial-ethnic groups except Native Americans Prevalence of alcohol abuse in 1991-1992 was 3.03%, increasing to 4.65% ten years later During the same period of time, the prevalence of alcohol dependence decreased significantly from 4.38% to 3.81% there was little change in the prevalence of alcohol dependence among women there were significant decreases reported for men and among whites and Hispanics Studies have also shown an increase in the prevalence of DSM-IV marijuana disorders in the general population between 1991-92 and 2001-02 (1.2%; 1.5%) There were significant increases in the prevalence of marijuana use disorders among young adult black men and women and among young Hispanic men although prevalence among white people remained high, there was no significant increase Lifetime prevalence of prescription opioid use disorder also increased, accompanied by a greater risk for prescription opioid use disorder in all birth cohorts. Recent birth cohorts show an increased risk of nicotine dependence among people who smoke Some studies show a greater prevalence of alcohol and illicit drug dependence among cohorts born after World War II.

Percentage of people with alcohol or other drug use disorders who never enter treatment

The stability of remission without formal treatment varies by sample and length of follow- up, but some studies report high rates of stability. Rumpf and colleagues, in a 24-month follow-up of a German community sample of people who had remitted from alcohol dependence without professional help, found a 91% remission rate at follow-up

Medications for methamphetamine addiction

There are no medications approved by FDA Mirtazapine, naltrexone, and bupropion have had positive results from clinical trials in human beings to reduce stimulant use or prevent relapse to MA or amphetamine type stimulants

Benzos in alcohol detox

There is significant high-quality evidence that supports management of AWS in inpatients with long-acting benzodiazepines preferable to use of short-acting benzodiazepines which carry a higher risk of delirium But short-acting benzodiazepines probably better in liver disease Outpatient use of benzodiazepine: there is evidence that benzodiazepines are safe, but the evidence is limited to one small (n=164) randomized prospective trial

True or false: SBIRT Is supported by evidence that it helps adolescents, that it works in primary care clinics, and I n general practice settings, and with patients with psychiatric disorders and co-occurring risky alcohol use. However in primary care clinics there is some evidence that it may not be as effective for women as men at one-year follow-up

True

True or false: caffeine consumption is lowest among patients dependent upon cocaine

True

True or false: group psychotherapy is the psychosocial treatment of choice for most patients with SUD's

True

True or false: large epidemiological studies suggest that nearly a quarter of alcohol users will become alcohol dependent at some point in their lives

True

True or false: some signs and symptoms of abstinence from heroin persist for weeks or months, particularly signs of hypothalamic - pituitary - adrenal ( HPA) axis hyperresponsivity

True

True or false: there are no significant differences between individual and group therapies in terms of substance use outcomes

True

True or false: treatment of physicians with sepsis uses orders is not supported by extensive research

True

True or false: a person who has less sedative and ataxic effects from acute alcohol consumption is more likely to develop alcoholism

True Interestingly this natural tolerance to alcohol put one at higher risk for alcoholism And this characteristic is more likely to lead to alcoholism then getting high rewards or euphoria from alcohol drinking, Or having control of oneself when drinking alcohol, or if alcohol reduces anxiety

True or false: the risk of developing addiction to opioids during the course of opioid treatment for chronic pain is unknown

True They range of addiction in various studies varies between 1% and 38%

True or false: The risk of the resumption of opioid use and opioid overdose increases rapidly following discontinuation of oral naltrexone and high mortality rates have been found following discontinuation of oral naltrexone maintenance treatment as compared to opioid agonist treatment

True Pooled studies from Australia show the rate of heroin overdose for patients after leaving naltrexone treatment was six times higher than the rate during naltrexone treatment and eight times higher than the rate among patients who left opioid agonist maintenance treatment

Leptin and ghretin

Two key hormones regulating food intake Both hormones are regulated by endocannabinoids in the Endocannabinol system (ECS)

membranoproliferative glomerulonephritis with type II cryoglobulinemia

Type of kidney failure associated with cocaine use

Concerning Drug Courts

Typical models last 12 to 18 months Can use positive reinforcement techniques like gift cards Urine toxicology is random An interlock device must be installed on the car's ignition system

Talking down the patient

Usually the best treatment for acute methamphetamine intoxication manifesting as agitation

Marijuana

When interacting with chlorpromazine may cause a relapse In patients who take chlorpromazine, smoking cannabis may increase chlorpromazine clearance due to cannabis's induction of the enzyme that clears chlorpromazine out of the body. Patients who display confusion, delusions, and hallucinations when smoking marijuana should cease marijuana use and carefully monitor their psychotic symptoms.

CIWA-Ar

a 10-item scale that is quick to administer and can be done in 3 minutes. requires patients to answer subjective questions such as auditory and visual disturbances, headaches, and orientation questions Scores of 8 and below are consistent with mild to no withdrawal and rarely require intervention Scores > 20 = severe withdrawal

The striatum

a brain structure that receives information from the prefrontal cortex innervates the basal ganglia Contains the VENTRAL STRIATUM the VENTRAL STRIATUM contains the NUCLEUS ACCUMBENS and the olfactory tubercle MEDIUM SPINY NEURONS are most prevalent type of cell in the striatum MEDIUM SPINY NEURONS express dopamine receptors The activity of these cells plays a crucial role in reward processing upon exposure to drugs and naturally-rewarding stimuli.

Reduce labeling and encourage bonding to the school and environment

a core principle of drug prevention programs that focus on educating youth on drug prevention in key entry points between middle and high school

Haloperidol

a first-generation antipsychotic YES it may be used in the pediatric population for acute psychoses, tourette syndrome and severe behavioral disorders It is CONTRAINDICATED in the elderly population who suffer from dementia It should be discontinued if the absolute neutrophil count falls below 1000 Pediatric patients with FAS have been known to have severe behavioral problems and therefore haloperidol is a short term pharmacologic option to use to aid in control of these acute behavioral problems.

6-monoacetylmorphine

a morphine metabolite Has only a small window of detection lasting several hours after use. Checked for if there is a suspicion of heroin use and a positive screen

Naltrexone

a partial opioid receptor antagonist potent inhibition at the mu opioid receptors modulation of the mesolimbic dopamine system in the VTA and projections to the nucleus accumbens meta-analysis of 27 randomized controlled trials = 36% reduction in the rate of relapse to heavy drinking Oral naltrexone hydrochloride is approved by the FDA at the dosage of 50 mg daily, although some clinicians have used 100 mg daily with the intention of maintaining an effective plasma concentration even if doses are missed Oral naltrexone has been effectively used to treat heroin addiction at doses of 100 mg-100 mg- 150 mg on a Monday, Wednesday, Friday schedule Oral naltrexone is most effective with compliant patients Oral naltrexone: one study raised questions of its efficacy in women Naltrexone antagonizes opioid-containing agents, but there are no other significant drug-drug interactions Side effects: abdominal pain, anorexia, and nausea & sedation in some = daytime sleepiness, fatigue, insomnia, or headache Reversible hepatotoxicity = check LFTs Injectable naltrexone: better adherence with once monthly dosing Injectable naltrexone: more stable plasma concentrations Injectable naltrexone: associated with more sedation Injectable naltrexone: increased efficacy at 380 mg dose compared to 190 mg doses = recommended dose is 380 mg monthly.

DSM-5 Alcohol use disorder

a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either of the following: A need for markedly increased amounts of alcohol to achieve intoxication or desired effect OR A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for alcohol OR Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Parental rejection

a strong predictor of substance use and conduct disorder in adolescent patients Parental rejection, family conflict, ineffective parental discipline, impaired parenting due to parental substance use, and parental mental health problems are among the most consistent and strongest predictors of adolescent substance use and CD Stronger predictor than: Recent move, small family or both alcohol and substance use Involved and supportive parenting is a protective factor against substance use.

DeltaFosB

a sustained molecular switch for addiction The longevity of some of the behavioral abnormalities that characterize drug addiction has suggested that regulation of neural gene expression may be involved in the process by which drugs of abuse cause a state of addiction. Increasing evidence suggests that the transcription factor DeltaFosB represents one mechanism by which drugs of abuse produce relatively stable changes in the brain that contribute to the addiction phenotype. DeltaFosB, a member of the Fos family of transcription factors, accumulates within a subset of neurons of the nucleus accumbens and dorsal striatum after repeated administration of many kinds of drugs of abuse. Similar accumulation of DeltaFosB occurs after compulsive running, which suggests that DeltaFosB may accumulate in response to many types of compulsive behaviors DeltaFosB persists in neurons for relatively long periods of time because of its extraordinary stability. DeltaFosB represents a molecular mechanism that could initiate and then sustain changes in gene expression that persist long after drug exposure ceases. Studies in inducible transgenic mice that overexpress either DeltaFosB or a dominant negative inhibitor of the protein provide direct evidence that DeltaFosB causes increased sensitivity to the behavioral effects of drugs of abuse and, possibly, increased drug seeking behavior. This work supports the view that DeltaFosB functions as a type of sustained "molecular switch" that gradually converts acute drug responses into relatively stable adaptations that contribute to the long-term neural and behavioral plasticity that underlies addiction.

primary cause of the intoxicating effect of alcohol on the brain

acts on GABA-ergic transmission in the brain.

actoins of ETOH

acts on NMDA subtype of glutamate receptor mechanism of action: uncompetitive NMDA channel antagonist

Physical Dependence

adaptions in the body that occurs by "resetting" homeostatic mechanisms in response to chronic exposure to an exogenous substance

Cannabis Use Disorder in US 12-month prevalence rates

adults = 1.5% adult men 2.2% adult women= 0.8% adolescents aged 12- to 17-years-old = 3.4% 12-month prevalence rates decrease with age peak among adults aged 18- to 29-years- old = 4.4% 65-years or older have the lowest 12-month prevalence rates = 0.01%

Alcohol use disorders

adults aged 18-29 were twice as likely to abuse alcohol than adults aged 30-44 men have a 12.9% dependence rate associated with alcohol abuse while women only have a 4.9% dependence rate Other risk factors: -- being Native American -- having any depression or anxiety disorder SURPRISINGLY there was NOT a strong relation between education level and alcohol abuse

Cocaine

an alpha-adrenergic agonist stimulates alpha-adrenergic receptors in the smooth muscle of the coronary arteries increases levels of endothelin-1, a coronary vasoconstrictor decreases production of nitric oxide, a vasodilator.

The basal forebrain

an area of the brain involved in the reinforcing effects of alcohol and other drugs comprised of a circuit called the "extended amygdala."

Epidemiology

approximately 46% of Americans have tried an illicit drug at least once in their lives Marijuana is the most commonly used drug, with 40% of Americans reporting lifetime use Changes in prevalence of marijuana use drive trends for estimates of "any illicit drug" use. The National Household Survey on Drug Abuse (NHSDA 1999) found marijuana consumption was reported by 15% of younger adults in the month prior to interview. Drug use increases from adolescence to young adulthood, with subsequent gradual decline reflected in most studies The risk of nicotine dependence is greatest in smokers in the most recent birth cohort Early age of smoking is a predictor of drinking and increases the risk for transition to alcohol abuse and dependence Current and past smoking are associated with onset of major depression in people ages 15 and over, but ONLY current smoking is associated with onset of substance use disorders, panic disorder, and agoraphobia. a stabilization or, in some cases, decline in illicit drug use after a relative peak in 1997, with an INCREASE in marijuana use and dependence, especially in YOUNG BLACKS and in HISPANIC people There has been an increase in the availability of high-purity heroin and an increase in heroin use through non-injection routes, including smoking. increase in initial use of MDMA (Ecstasy) expansion of the use of other "club drugs." decline in use of LSD cocaine use has stabilized and shows some signs of decline. The Monitoring the Future Study is a school-based study that resulted in higher estimates of illicit drug use compared to the National Survey on Drug Use and Health. This is attributed to sample differences from collection of data in schools instead of households. Methodological differences in question technique may also account for the higher estimates obtained in this study. The Monitoring the Future study has documented and described the relationship between drug use and other variables, including the relationship between marijuana use and beliefs about the harmfulness of that substance. The National Comorbidity Survey data highlights the significance of adolescent drug use, reporting that half of all adolescent drug users surveyed progressed to drug abuse

cocaine epidemiology (2013)

approximately 601,000 people aged 12 and older tried any form of cocaine for the first time within the past 12 months (1,600 cocaine initiates per day) lower than figures from 2007 where there were approximately 2,750 cocaine initiates per day. estimated 12-month prevalence of Cocaine Use Disorder in the United States is 0.2% among 12- to 17-year-olds and 0.3% among adults. Like most substance use disorders, rates are higher among males (0.4%) than females (0.1%). prevalence rates for US population subgroups are as follows: Native Americans (0.8%) African Americans (0.4%) Hispanics (0.3%) White/Caucasians (0.2%) Asian Americans and Pacific Islanders (0.1%)

CB1 receptors

are coupled with G proteins G proteins catalyze protein phosphorylation and inhibit c-AMP dependent protein kinase A to result in the known cannabinoid actions.

CYP2A6*10 allele

associated with decreased nicotine metabolism patients with this particular variant tend to smoke fewer cigarettes per day On exposure to nicotine, individuals with the CP2A6*1X2A genotype tend to exhale higher levels of carbon monoxide compared to other variants plasma cotinine levels are higher CP2A6*1X2B allele associated with increased nicotine metabolism when compared to wild type CP2A6*2 allele associated with longer nicotine half-life and reduced metabolism smoke fewer cigarettes per day and are more likely to successfully quit smoking when compared to those with other genotypes. response to transdermal nicotine replacement therapy is superior adolescents with this genotype have increased risk of nicotine dependence CP2A6*4 allele associated with reduced metabolism of nicotine Like those with the CP2A6*2 genotype, adolescents are at increased risk of nicotine dependence Patients with this genotype tend to smoker fewer cigarettes per day more able to successfully quit smoking, when compared to those with other genotypes respond well to transdermal nicotine replacement therapy CP2A6*1/*12 allele tend to have normal metabolism of nicotine CP2A6*9/*12 allele decreased metabolism of nicotine CP2A6*12 allele associated with fewer cigarettes per day better response to transdermal nicotine replacement therapy. CP2A6*17 allele associated with increased ability to successfully quit smoking nicotine metabolism is reduced CP2A6*35 allele associated with reduced nicotine metabolism enhanced ability to successfully quit smoking.

Benzodiazepine use in pregnancy

associated with twice the normal risk of cleft palate and with floppy baby syndrome and withdrawal

Therapeutic community

average 6-12 months therapeutic focus: "re-socialization" Treatment = highly structured can be confrontational. The aim is to push residents to examine their often detrimental beliefs, self-concepts and patterns of behavior and learn new ways or more harmonious interactions, relationships and interactions with others in their community Length of stay matters: abstinence success rates are 90% for 2-years but only 25% that leave earlier than recommended.

there is no significant difference in cannabis abuse

between people of different races.

11-hydroxy-∆9-tetrahydrocannabinol

cannabis chemical that is most active in the central nervous system

breathalyzer test analyzes breath samples for metabolites of disulfiram. These metabolites are:

carbon disulfide and acetone

Benzodiazepines

cause hyperpolarization of the cell membrane bind to one of the subunits of the GABA -A receptor cause increased flow of Cl- ions through the receptor increases the receptor's affinity for available GABA do NOT increase GABA

opiate agonists

cause phosphorylation of the opiate receptors bind opiate receptors, causing the inhibition of adenylate cyclase that causes several chemicals in the cell to maintain the firing of impulses

Alcohol and Opioids

cause sexual dysfunction during both substance intoxication and withdrawal

Stimulants (amphetamine-type substances & cocaine)

cause sexual dysfunction during intoxication and not withdrawal

Use of an avoidant style for coping with problems

characteristic found to be predictive of affiliation with Alcoholics Anonymous (AA)

ion implicated in the clinical effects of benzodiazepines

chloride

1, 3, 9, 14

chromosomes linked to developing a cannabis use disorder

extended amygdala

circuit in basal forebrain (or perhaps synonymous with "basal forebrain") It is thought that this circuit regulates neuroadaptations that are associated with drugs of abuse includes the nucleus accumbens (medial area) and the amygdala (centromedial area)

Opioid Antagonists

class of medications that has demonstrated the greatest efficacy in the treatment of gambling disordet

PCP (angel dust)

classic toxidrome of PCP intoxication: violent behavior, nystagmus, tachycardia, hypertension, anesthesia, and analgesia binds to NMDA receptors, acts as a monoamine reuptake inhibitor, stimulates σ-opioid receptors, as well as nicotinic, muscarinic and GABA receptors patients may exhibit hyperreflexia, and myoclonic, dystonic or choreoathetoid movements such as opisthotonos and torticollis Most deaths in PCP-intoxicated patients, however, result from patients' violent behavior, rather than direct effects of the drug.

The Monitoring the Future survey

collects data each year on the attitudes and drug use habits of approximately 50,000 nationally representative students in grades 8, 10, and 12

Acceptance and commitment therapy

combines acceptance therapies to focus on behaving in ways that promote valued goals, rather than behaving in the service of avoidance of discomfort. This type of therapy can improve pain, reduce fear of reinjury and interference, and enhance quality of life

Mindfulness

commonly used along with acceptance and commitment therapy. The relaxation response, which is the converse of the stress reaction, can be elicited by such techniques as deep breathing exercises, guided imagery, meditation, progressive muscle relaxation, yoga, and tai chi.

Project MATCH

compared Cognitive-Behavioral Therapy, 12-Step Facilitation Therapy, and Motivational Enhancement Therapy early 1990's was the largest study of psychotherapies for alcohol use disorders to date Over 1700 patients at 9 sites across the country were randomized to three treatments: Cognitive-Behavioral Therapy, 12-step Facilitation Therapy, and Motivation Enhancement Therapy All three methods produced roughly equivalent clinical improvements which were stable over the three years patients were followed Angry patients and those with lower initial motivation did better with MET Patients with little social support for abstinence did better in the long run when treated through 12-step Facilitation Therapy Patients with more severe alcohol dependence did better in 12-step Facilitation Therapy than CBT, while those with less severe alcohol dependence showed the opposite effect.

Pharmacokinetic tolerance

consequence of increased metabolism of a drug after its repeated administration resulting in less drug available at the target receptors

heroin overdose syndrome

consists of a symptom triad: 1. altered mental status 2. depressed respirations and 3. miotic pupils

Naloxone (Narcan)

contraindicated in infants whose mothers are known to be dependent on opioids UNLESS in the absence of a specific history of opioid abuse in a mother who has recently received narcotics, naloxone treatment remains a reasonable option in the delivery room management of a depressed infant if the infant continues to demonstrate respiratory depression after positive pressure ventilation has restored normal heart rate and color.

Nicotine withdrawal

craving, irritability, frustration, anger, depression difficulty concentrating, restlessness, increased appetite impaired reaction time and attention during withdrawal Symptoms reach peak 24 to 48 hours after stopping and gradually dissipate over 2-3 weeks

NESARC-III on Alcohol Use Disorder (AOD)

data collected from April 2012 through June 2013 and analyzed in October 2014 Twelve-month and lifetime prevalences of AUD were 13.9% and 29.1%, respectively Prevalence highest for men (17.6% and 36.0%, respectively), white (14.0% and 32.6%, respectively) and Native American (19.2% and 43.4%, respectively), respondents, and younger (26.7% and 37.0%, respectively) and previously married (11.4% and 27.1%, respectively) or never married (25.0% and 35.5%, respectively) adults. Prevalence of 12-month and lifetime severe AUD was greatest among respondents with the lowest income level (1.8% and 1.5%, respectively). Significant disability was associated with 12-month and lifetime AUD and increased with the severity of AUD Only 19.8% of respondents with lifetime AUD were ever treated Significant associations were found between 12-month and lifetime AUD and other substance use disorders, major depressive and bipolar I disorders, and antisocial and borderline personality disorders across all levels of AUD severity, with odds ratios ranging from 1.2 (95% CI, 1.08-1.36) to 6.4 (95% CI, 5.76-7.22) Associations between AUD and panic disorder, specific phobia, and generalized anxiety disorder were modest (odds ratios ranged from 1.2 (95% CI, 1.01-1.43) to 1.4 (95% CI, 1.13-1.67) across most levels of AUD severity.

Serotonin

deficiencies are linked to disorders characterized by a loss of behavioral control

Najavits' Seeking Safety treatment for PTSD and substance use disorders

developed as a way of addressing PTSD and substance use for women who are in the early phases of recovery from both disorders designed to teach coping skills relevant to both PTSD and substance abuse while emphasizing the initial treatment goal of establishing safety defines safety broadly to include physical safety (e.g., a battered woman insuring her safety from her abuser), and psychological (e.g., teaching patients to use distraction techniques rather than substances to manage intrusive symptoms of PTSD) The therapy explicitly does not include discussion of traumatic memories as this is viewed as fodder for a later stage is established the establishment of Safety is typically a prerequisite to trauma processing

AUDIT

developed by the World Health Organization WHO AUDIT has 10-items the shorter version of AUDIT called AUTI-C has 3 items Scores > 8 in men over 60 years old are considered positive Scores ≥4 for women, adolescents, and men over 60 are considered positive Positive scores suggest a problem that needs further investigation but scores do not correlate with alcohol dependence

Dissasociatives

dissasociatives: ketamine, dextromethorphan, PCP, nitrous oxide NMDA receptor antagonist noncompetitively block NMDA receptors to filter sensory stimuli = sensory overflow increased heart rate, blood pressure, temperature CPK, urine myoglobin rarely see dilated pupils like stimulant-, hallucinogen-, or opioid-withdrawal Visual hallucinations rare

Inhalants and Phencyclidine

do not cause sexual dysfunction with either substance intoxication or withdrawal

$5

dollars saved in costs for drug treatment and counseling for every dollar spent on drug abuse prevention

SB-277011-A

dopamine D3 receptor antagonist potential for helping opiate addiction has shown great promise in the treatment of addictive disorders decreases cue-induced reinstatement of nicotine and cocaine seeking modifies activity of dopaminergic neurons and lower ethanol intake in rats.

The ECA Surveys

earliest epidemiologic study assessing psychiatric and substance use disorders 1980-1984 conducted by the National Institute of Mental Health over 20,000 adult participants ages 18 and older in five metropolitan areas DSM-III lifetime prevalence and one-year prevalence of alcohol abuse and dependence between male (23.8%, 11.9%) and female (4.7%, 2.2%) higher lifetime prevalence of drug use and drug use disorders among men (7.7% compared to 4.8% among women) proportional difference in alcohol use disorders is much greater between men and women compared to the proportional difference in illicit drug use disorders However, among DRUG USERS THE LIFETIME PREVALENCE WAS SIMILAR: 21% vs 19% Most epidemiological surveys have consistently demonstrated gender differences in alcohol and drug use disorders Women drinkers are less likely to develop alcohol dependence or to have persistent dependence Gender differences differ by specific substance and within certain age groups Employment is related to alcohol use and occurrence of alcohol disorders. ECA: unemployed 6 months or more in the preceding 5 years had higher prevalence rates of alcoholism and greater risk for alcohol use disorders.

Selective G-protein-coupled opioid receptor κ-agonist drugs

experimental drugs such as ethylketazocine and bremazocine less addictive than μ-drugs analgesia + dysphoria + diuretic effects BUT NO RESPIRATORY DEPRESSION Likely less abusive

Score on Fagerström Test for Nicotine Dependence

factor that correlates most strongly with the severity of nicotine addiction

Desipramine (Norpramin)

false positive AMPHETAMINES

Poppy seeds, rifampicin, ofloxacin (ear drops), and levofloxacin

false positive drug tests for opiates

Bupropion (Wellbutrin)

false positive for amphetamines

Labetalol HCl

false positive for amphetamines

Psilocybin (shrooms)

feels good; treats emotional sufferings cancer patients

delirium tremens

fluctuating consciousness, global amnesia, hallucinations usually tactile or visual, persecutive delusions, impaired attention treat with lorazepam begins 48-96 hours after last drink can last for two weeks symptoms worse towards evening can have seizures can be fatal

FAAH

gene involved in striatal activation to marijuana cues withdrawal reactions and craving behaviors in patients who abuse marijuana.

Make cocaine-taking aversive

goal of pharmacologic treatment of cocaine dependence

OPRD1

good response to methadone maintenance

Anabolic steroid use is associated with an increased risk of:

gynecomastia

National Comorbidity Survey

half of adolescent drug users developed drug abuse or dependence

Flumazenil (Romazicon)

half-life approximately 55 minutes.

2 hours

half-life of nicotine

3-5 drinks on an episodic or daily basis

harmful drinking, as described by the National Institute on Alcohol Abuse and Alcoholism

Caffeine withdrawal

headaches, fatigue, drowsiness, impaired concentration, and depressed mood

CYP2A6*1B.

heavier smokers in the metabolism of nicotine, 70 to 80% of nicotine is metabolized to cotinine in a 2 step process involving CYP2A6 Genetic variation in the gene coding for CYP2A6 is an important factor in the speed at which nicotine is metabolized depending on the genetic variant, patients may be slow metabolizers, intermediate metabolizers, normal metabolizers, or ultra-rapid metabolizers Smoking habits including number of cigarettes smoked per day can correlate to different genetic variants Using star nomenclature, wild type CYP2A6 is denoted CYP2A6*1 When compared to the individuals homozygous for the wildtype CYP2A6 (CYP2A6 *1A/*1A) CYP2A6*1B is associated with increased nicotine clearance Individuals homozygous for the CYP2A6*1B genotype tend smoke more cigarettes per day, when compared to those homozygous for CYP2A6 *1A

For a pregnant woman who is abusing alcohol, tobacco, heroin and marijuana, which substance is most likely to cause preterm labor?

heroin

One way in which gene expression can be altered by drug exposure is through modification of ______________ acetylation.

histone

2-3 days

how long after use of cocaine will urine toxicology test likely be able to detect use

Tobacco/cigarette smoking is associated with an increased risk of:

hyperlipidemia, hypogonadism/infertility, hypertension, thyroid disease including Graves disease, osteoporosis, diabetes mellitus, and syndrome of inappropriate antidiuretic hormone

Rifampicin

if started in someone who is on methadone maintenance treatment, could precipitate opioid withdrawal symptom

GABRA2

impulsivity and external behavioral problems in patients who abuse alcohol

"heavy drinkers"

include both at-risk individuals, as well as symptomatic drinkers (meeting criteria for an alcohol use disorder about twice as many meet criteria for alcohol use disorder as compared those meeting criteria for heavy drinking has physical consequences including liver damage, hypertension and gastrointestinal cancers

Results from the National Epidemiologic Survey on Alcohol and Related Conditions (2001-2002 NESARC)

lifetime cumulative probability estimates of dependence remission for alcohol = 90.6% lifetime cumulative probability estimates of dependence remission for cocaine = 99.2% median time for remission from alcohol is 14 years median time for remission from cocaine is 5 years median time for remission from nicotine is 26 years most individuals with nicotine, alcohol, cannabis, and cocaine dependence achieve remission at some point The probability and time to remission vary by racial/ethnic group and by substance Over two-thirds remission from dependence on cannabis and cocaine occurred within a decade of onset of dependence only one-fifth of remissions from nicotine dependence occurred within a decade of onset of dependence only one-third of remissions from alcohol dependence occurred within a decade of onset of dependence individuals with dependence on nicotine had the highest rates of early substance abuse onset, followed by cannabis, alcohol, and cocaine. one third of patients with nicotine of alcohol dependence had a lifetime diagnosis of a mood, anxiety, or personality disorder almost two thirds of those with cannabis or cocaine dependence had a lifetime diagnosis of a mood, anxiety, or personality disorder Males, blacks, and individuals with comorbid personality disorders and history of substance abuse comorbidity had lower hazards for remission for at least two substances.

defecation

mechanism of marijuana elimination allows for the largest amount of marijuana to be eliminated from the body ~ 65% via feces and 20% via urine

IV-D

medically managed inpatient detoxification, for severe unstable withdrawal requiring 24-hour nursing care and daily physician visits to modify detoxification regimen and manage medical instability

III.7-D

medically monitored inpatient detoxification, for severe withdrawal in patients who need 24-hour nursing care and physician visits as necessary recommended for patients who are otherwise unlikely to complete detox.

GHB (gamma hydroxybutyric acid)

member of the sedative-hypnotic class of drugs first synthesized as an analog of GABA acts at two receptor sites in the brain, the GABA-B and specific GHB receptors leads to CNS depression, stimulation, and psychomotor impairment Intoxication is dose dependent: -- Low doses stimulate release of dopamine -- higher doses inhibit dopamine release Ingestion of GHB results in enhanced sexual response, altered states of consciousness, and increased socialization Objective responses to the drug include sedation, decreased psychomotor performance, and muscle relaxation Approximately 95% of the drug is metabolized in the liver half-life of 30-60 minutes only five percent of the parent compound is excreted through the kidneys detection in urine is difficult after 24 hours GHB has a high overdose risk associated with use due to pure dose consistency and steep dose response curve Overdose can result in bradycardia, vomiting, somnolence, nystagmus, obtundation, stupor, coma, agitation, combative behavior, self-injury, respiratory depression, and death There is an additive effect with other CNS depressants In addition to use as a club drug, GHB has also been used illicitly for bodybuilding Severe dependence and withdrawal may result from use.

Depression

most common co-morbid psychiatric condition in patients that present for treatment of a substance abuse disorders

Supraventricular tachyarrhythmia

most common type of cardiac rhythm disturbance in chronic alcohol abuse or withdrawal

ARGININE --->ASPARTIC ACID

most commonly found mutation in OPRM1 gene that leads to increased risk of alcohol relapse

OPRM1

mutated OPRM1 = less reduction of heavy drinking when prescribed naltrexone effects: Opioid dependence HPA axis response to stress Sensitivity to pain Responsiveness to analgesics

methadone + Zidovudine =

myriad of unwanted side effects such as muscle pain, insomnia, and dysphoria methadone increases zidovudine levels by 41%

Meperidine (Demerol)

opioid that has anticholinergic properties anticholinergic properties produce mydriasis with cycoplegia other opioids show classic miosis on presentation.

Buprenorphine

partial agonist at the mu-opioid receptor and an antagonist at the kappa-opioid receptor.

Varenicline (Chantix)

partial agonist of the alpha 4 beta 2 subunit of the nicotinic acetylcholine receptor

II.5

partial hospitalization, or 20 or more hours of service weekly for multidimensional instability not requiring 24-hour care

mesolimbic pathway

patient with an addiction to cocaine is at his or her highest risk of relapse three to four weeks after their last use of cocaine due to reduced neuronal activity in this neurocircuit pathway

1 in 5

patients on chronic opioid analgesic therapy who will develop OUD as defined by DSM-5 if tolerance and withdrawal are considered, the prevalence rises to nearly 1 in 3

Medium spiny neurons

principal neurons of the striatum GABAergic and, thus, classified as inhibitory neurons comprise 95% of the total neuronal population of the human striatum have two primary phenotypes: D1-type MSNs of the direct pathway and D2-type MSNs of the indirect pathway A subpopulation of MSNs contain both D1-type and D2-type receptors, with approximately 40% of striatal MSNs expressing both DRD1 and DRD2 mRNA

32%

probability of becoming dependent on tobacco after trying the substance once

The Americans with Disability Act (ADA)

prohibits discrimination against individuals who are in recovery from impairing medical conditions The ADA has been used very effectively to protect the interests of patients in recovery who have employment issues

The drug most biochemically related to methadone

propoxyphene (Darvon)

marijuana (pot or weed)

protective factor against seizures for men

Confidentiality of Alcohol and Drug Abuse Patient Records

protects the privacy of treatment records and can be accessed only with written permission of the patient to disclose specific information. Significantly it does not allow for disclosure of the protected information

COMBINE

randomized patients with alcohol dependence to varying combinations of oral naltrexone, acamprosate, combined behavior intervention, and medical management One patient cohort received only psychotherapy and half of patients received both psychotherapy and medical management. revealed an increase in the percentage of days abstinent in all treatment groups For patients receiving medical management, naltrexone, or CBI therapy, patients receiving naltrexone and medical management had the best outcome Acamprosate was no more effective than placebo plus medical management acamprosate added no benefit to naltrexone therapy or combined behavioral intervention .At one year follow-up, there were no significant difference among treatment cohorts.

Nicotine

reaches brain 20 secs after inhalation half-life 2 hours or more likes alkaline -- high pH metabolized primarily in the liver 80% is metabolized to cotinine (by CYP2A6) Women metabolize nicotine faster than men Women who take estrogen metabolize nicotine even faster The metabolism of nicotine is even faster during pregnancy African-Americans clear nicotine more slowly then Caucasians getting about 30% more nicotine Black men have a higher mortality from lung cancer then do White men Chinese Americans get less nicotine per cigarette and smoke if you were cigarettes per day then do Caucasians Chinese Americans metabolize nicotine more slowly than Caucasians or Hispanic Americans Chinese Americans have a lower lung cancer rate than Caucasians or African-Americans

alpha-4-beta-2 - nicotinic postsynaptic

receptors on dopamine neurons in the ventral tegmental area to which Nicotine binds to directly release dopamine in the nucleus accumbens

Serotonin (5-HT)

reduced in the cerebrospinal fluid (CSF) in many alcohol abusers, predisposing certain people to uncontrollable drinking behavior

Aberrant behaviors

requesting a specific drug demonstrating reluctance to undergo a full evaluation and diagnostic tests refusal of permission to communicate with prior physicians or to obtain old records claiming multiple allergies to recommended medications resisting other treatment interventions aggressive or threatening behavior giving excessive flattery losing a prescription repeatedly demonstrating noncompliance with prescription instructions demonstrating other evidence of alcohol or illicit drug misuse.

DSM-5 Cannabis-induced sleep disorder

requires a prominent and severe disturbance in sleep The disturbance must not occur exclusively during the course of delirium The disturbance must also cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Evidence from the history, physical examination, or laboratory findings must suggest both of the following: The symptoms in the first criterion developed during or soon after cannabis intoxication, or after withdrawal from or exposure to it. Cannabis is capable of producing the symptoms in the first criterion. The disturbance is not better explained by a sleep disorder that is not substance/medication-induced. Such evidence of an independent sleep disorder could include that symptoms precede the onset of the cannabis use; symptoms persist for a substantial period (ie, about a month) after the cessation of acute withdrawal or severe intoxication; or other evidence that suggests an independent nonsubstance/medication-induced sleep disorder (ie, a history of recurrent nonsubstance/medication-related episodes).

DSM-5 Sustained remission for cannabis use disorder

requires that none of the criteria for cannabis use disorder have been met at any time during a period of 12 months or longer (with an exception for craving)

Yale Food Addiction Scale (YFAS)

screening instrument that has been validated for use in adults by applying substance abuse criteria to food validated in an fMRI study.

Biofeedback/relaxation training

seeks symptom control through electronic feedback to teach patients to regulate body functions that are not usually under voluntary control (e.g. skeletal muscle tension, palmar sweating, gastrointestinal motility, and digital blood flow).

SOAPP-R

self-administered instrument can be done prior to opioid therapy reliable and valid predictor of aberrant behavior after 5 months of therapy Patients at higher risk tended to be younger, endorse more pain, have higher morphine equivalent daily dose requirement, and endorse more symptoms of depression and anxiety.

PDUQp (Modified Prescription Drug Use Questionnaire)

self-administered instrument which screens for the presence of substance use disorders in patients with chronic nonmalignant pain comprehensive instrument that has been modified for self-administration (PDUQp, where "p" stands for patient).

FAS (fetal alcohol syndrome)

short palpebral fissures thin upper lip long, smooth philtrum flat midface ptosis of the eyelids epicanthal folds upturned nose with a flat nasal bridge underdeveloped ears clinodactyly of the fifth fingers camptodactyly "hockey stick" palmar creases hirsutism cardiac defects Prenatal or postnatal growth retardation typically results in a height or weight below the 10th percentile for age and race Microcephaly structural brain anomalies CNS impairment may not be apparent in newborns Cognitive deficits appear in school-aged children attention-deficit/hyperactivity Facial findings may become less characteristic by adolescence or adulthood

Buprenorphine induction

should not begin until 12-24 hours after opioid use, in the case of short-acting opioid use If a patient presents on day 2 of induction with symptoms of withdrawal, the total dosage from the first can should be added to 4/1 mg of buprenorphine/naloxone, and may receive subsequent increases in dosage until the total daily buprenorphine dose reaches 16 mg. The maximum daily dose of buprenorphine/naloxone by the end of the first week is 32/8 mg If a patient experiences continued opioid withdrawal by the end of the first week, clinicians should suspect illicit opioid use Stabilization lasts one to two months in most patients During stabilization, the minimum dosage to eliminate withdrawal symptoms, reduce cravings, and minimize side effects should be determined, by frequent contact with the physician to enable dose adjustments and monitor compliance. Psychosocial issues should begin to be addressed during this phase. The maintenance phase can be indefinite, with a determination of the best length of treatment made in consideration of the needs of the individual patient.

Universal precautions in chronic opioid treatment

similar to the approach used for infectious disease Universal precautions are used with all patients, regardless of their risk factors for a contagious condition The 10 steps of universal precautions in pain medicine include the following: 1. Diagnose the cause of pain 2. Conduct a psychological assessment, including addiction risk 3. Ensure informed consent 4. Create treatment agreement 5. Assess pain and function pre- and post-intervention 6. Conduct opioid trial +/- adjunctive medication 7. Continue reassessing pain and function 8. Regularly assess the "four As" (analgesia, activity, adverse effects, aberrant behavior, +/- affect) 9. Periodically review diagnoses, including addiction 10. Keep careful documentation

CHRNA5

smoking cessation interaction with pharmacotherapy to stop smoking addiction

CHRNA5

smoking cessation interaction with pharmacotherapy to stop smoking addiction mutated CHRNA5 = HIGHER tobacco smoking addiction while having a LOWER cocaine addiction

CYP2A6

smoking relapse.

True

some beneficial effects of longer stays in inpatient/residential treatment apply only to more impaired patients with fewer social resources

over 75%

studies have found that ___________________ of patients with cocaine associated chest pain undergoing angiography have evidence of significant coronary artery stenosis

Fagerström Test for Nicotine Dependence

studies show relationship between this test and smoking cessation

pharmacodynamics

study of dose response phenomena of the drug actions and adaptive body responses.

Pharmacokinetics

study of the interactions of genetic polymorphisms, pharmacokinetic and pharmacodynamics

Hyperacusis

symptom of benzodiazepine withdrawal

Bradycardia

symptom of cocaine withdrawal

Type II alcoholism

teen onset severe prognosis tendency to become involved with many other drugs likelihood of attention and learning problems deviancy related to thrill seeking and risk taking heritability estimated at 80%.

dependence to cannabis is much more common in:

teenagers aged 12-17 than in adults 35 or older in a ratio of nearly 2:1. males are twice as likely to abuse marijuana compared to females Having a lower education level (high school vs. college) patients who come from poor families

Limits for valid urine sample

temperature between 90 and 100 degrees Fahrenheit urine pH between 4.5 and 8.5 nitrite concentration less than 5.0 mg/dL creatinine concentration greater than 2.0 mg per dL an unusual specimen appearance

Marijuana

the concurrent use of ________________ with TCAs or anticholinergic drugs can produce significant tachycardia.

The "telescoping effect" of SUD's in women

women advance more rapidly than men from initial to regular use and to first treatment episode women have fewer years of use and use smaller quantities at treatment entry But, their symptoms-severity is generally equivalent to men with women having significantly more medical, psychiatric, and adverse social consequences as a result of their addictions

Phencyclidine (PCP)

works primarily at the NMDA glutamate receptor

Caffeine

world's most widely used psychoactive drug associated with pulmonary complications with a large overdose

Results from multiple epidemiological studies done on alcohol use show that

~ 51% of adults use alcohol at least once per week Men under age 65 who drink more than 14 bottles of beer a week are at much higher risk for alcohol-related diseases Roughly 85,000 deaths in the United States occur each year due to alcohol use Roughly 10% of deaths in working age adults results from excess drinking The lifetime prevalence rate of alcohol dependence is 12.5%

receptor types thought to be the primary targets of nicotine's reinforcing properties

α-4, β-2 receptors

Enkephalins bind to

δ-opioid receptors (DORs)

Dynorphins bind to

κ-opioid receptors (KORs)