Substance use disorders Varcarolis

Opioid withdrawal treatment

1. Methadone (Dolophine, Methadose) - synthetic narcotic opioid used to decrease the painful symptoms of opiate withdrawal and block the euphoric effects of opiate drugs such as heroin, morphine, and codeine, as well as semisynthetic opioids like oxycodone and hydrocodone. Methadone is only dispensed through an opioid treatment program certified by SAMHSA. Once-a-day dosing is adequate. Will eventually need to be withdrawn via tapering or substituting another medication. In pregnancy, a low dose of methadone may be safest as neonate withdrawal is usually mild and can be managed with paregoric. 2. Clonidine (Catapres) - an alpha agonist antihypertensive, is often used to reduce the symptoms of opioid withdrawal; blocks neurotransmitters that trigger sympathetic nervous system activity, so it eases sweating, hot flashes, watery eyes, and restlessness. This drug also decreases anxiety and may even shorten the detox process. 3. Lofexidine (Lucemyra) - another alpha agonist, has FDA approval for the mitigation of opioid withdrawal symptoms during abrupt discontinuation; enables people to withdraw at home in a few days rather than a week. However, cost is $1,700 for a week's worth of treatment compared to $1 for clonidine. 4. Buprenorphine is also used to help people reduce or quit opiates; is an opioid partial agonist. Produces effects such as euphoria or respiratory depression, but are weaker than those of drugs such as heroin and methadone.

opioid OD tx

1. Promote breathing by aspirating secretions (suction), inserting airway, and mechanical ventilation. 2. Naloxone (Narcan) is the antidote; may be given intranasally, IM, subq, or IV. Duration of action for naloxone is short so repeated admin may be required; too much naloxone may produce withdraw symptoms.

Symptom groups of substance use disorder

1. impaired control 2. social impairment 3. risky use 4. physical effects (i.e., intoxication, tolerance, withdrawal)

PCP intoxication treatment

1st line treatment = Benzodiazepine - lorazepam and diazepam can be given by IV, which is best since patients are often so agitated they cannot take anything by mouth 2nd line treatment when benzo doesnt work = Haloperidol 3rd line if all else fails = propofol Patients cannot be talked down and may require restraint. Mechanical cooling may be necessary for severe hyperthermia.

Cannabis intox tx

Abstinence and support are main principles. Antianxiety meds may be helpful for short term relief of withdrawal symptoms. Patients with underlying anxiety and depression may respond to antidepressant therapy.

Alcoholism risk factors: Environmental- Social

Adolescents may be strongly influenced by their peers to engage in substance use. Alcohol, which has been referred to as a "social lubricant," may increase an adolescent's feeling of belonging. Using alcohol, tobacco, and marijuana at an early age is strongly associated with coming from a home with low parental supervision.

Alcoholism risk factors: Genetic

Alcohol use disorder runs in families and about 40%-60% of the risk comes from inheritance. Monozygotic (identical) twins are more likely to share alcohol use problems than dizygotic (fraternal) twins. Monozygotic male twins are more likely to share alcohol use disorder than are female twins. Certain alleles of the alcohol dehydrogenase and aldehyde dehydrogenase genes can cause a buildup of acetaldehyde that creates the classic flushing response.

Sedative, hypnotic, and antianxiety withdrawal symptoms

Autonomic hyperactivity, tremor, insomnia, psychomotor agitation, anxiety, and grand mal seizures. The degree and timing of the withdrawal syndrome depends on the specific substance. Half-life is an important predictor of time.

Tobacco withdrawal treatment

Behavioral therapy is useful to teach the patient to recognize cravings and respond to them appropriately. Hypnosis has been used successfully to treat tobacco withdrawal. Nicotine replacement therapies in the form of gum, lozenges, nasal sprays, inhalers, and patches are highly successful treatments. Two drugs have FDA approval for nicotine cessation. The antidepressant bupropion (Zyban) reduces the cravings for nicotine and withdrawal symptoms. Varenicline (Chantix) is a nicotinic receptor partial agonist that mimics the effects of nicotine, thereby reducing cravings and withdrawal. It also partially blocks the nicotine receptors, which blunts the effect of nicotine if smoking is resumed

alcohol use disorder (alcoholism) comorbidities

Bipolar disorders, schizophrenia, and antisocial personality disorder are associated with an increase in rates of alcohol use disorder. Major depressive disorder is a risk factor for and a result of alcohol use disorder due to alcohol's depressant qualities. Alcohol may also reduce the immune response and predispose users to infection.

Wernicke-Korsakoff Syndrome

Brain and memory disorder that requires immediate treatment. Occurs due to lack of thiamine (vitamin B1). Wernicke's (alcoholic) encephalopathy is acute and reversible; while Korsakoff's syndrome is chronic with a recovery rate of only 20%.

Alcohol withdrawal symptoms

Classic sign is tremulousness (shakes, jitters)- appears 6-8hrs after alcohol cessation. Mild to moderate wd- agitation, lack of appetite, n/v, insomnia, impaired cognition, mild perceptual changes. systolic and diastolic bp increase, pulse increase, and temp increase. Chlordiazepoxide (Librium) is useful for tremulousness and mild to moderate agitation. Withdrawal seizures may occur within 12-14hrs after alcohol cessation; generalized and tonic-clonic. Diazepam (Valium) given IV is a common treatment for withdrawal seizures. Disulfiram may be ordered to maintain the aversion to alcohol. Ingestion of alcohol while taking disulfiram produces a toxic reaction causing intense n/v, headache, sweating, flush skin, respiratory difficulties, and confusion.

Hallucinogens

Drugs that alter moods, thoughts, and sense perceptions including vision, hearing, smell, and touch. Associated with flashbacks, panic attacks, psychosis, delirium, and mood and anxiety disorders. Schedule 1 controlled substance- no medical use and high abuse potential. Divided into 2 broad categories: Classic (e.g., LSD) and Dissociative (e.g., PCP and Ketamine).

Stimulant withdrawal treatment

For amphetamines, an inpatient setting is usually necessary. Individual, family, and group therapy are helpful. Depending upon the amphetamine used, specific drugs may be used short term. Antipsychotics may be prescribed for a few days. If there is no psychosis, diazepam (Valium) is useful in treating agitation and hyperactivity. Once the patient has been withdrawn from the amphetamine, depression can be treated with antidepressants such as bupropion (Wellbutrin).

Behavioral addictions aka process addictions

Gambling, internet gaming, social media, shopping, and sexual activity.

Risk Factors: Biological Factors

Genetic and Neurobiological Genetic: substance use disorders such as cannabis, cocaine, and opiates run in families. Neurobiological: People with too little natural opioid activity or too much opioid antagonism may be prone to self-medicating with opioid drugs. Major neurotransmitters involved in developing substance use disorders are the opioid, catecholamine (especially dopamine), and gamma-aminobutyric acid (GABA) systems. The dopaminergic neurons in the ventral tegmental area (VTA) are especially important in the sensation of reward.

Sedative, hypnotic, and antianxiety withdrawal treatment

Gradual reduction of benzodiazepines will prevent seizures and other withdrawal symptoms. Barbiturate withdrawal can be aided by using a long-acting barbiturate such as phenobarbital.

Caffeine OD tx

Hydration, either oral or IV; gastric lavage; activated charcoal to bind caffeine if ingestion was recent; beta blockade for tachycardia; vasopressors to help maintain blood pressure without worsening tachycardia.

Alcoholism risk factors: Neurobiological

Individuals from families with a history of alcohol misuse have altered amygdalar, hippocampal, basal ganglia, and cerebellar volume. Functional magnetic resonance imaging studies show altered inhibitory control and working memory brain response in these individuals. There may be brain activity differences in areas involved in emotional and instinctual reward processing.

Scheduled 4 drugs

Low risk drugs available by prescription. Examples include alprazolam (Xanax), lorazepam (Ativan), and propoxyphene/acetaminophen (Darvocet).

Scheduled 3 drugs

Low to moderate potential for misuse and are available only by prescription. Examples include Testosterone, Tylenol w/ Codeine and buprenorphine (Suboxone)

Opioid withdrawal symptoms

Mood dysphoria/Anxiety, N/V/diarrhea, muscle aches, fever, and insomnia. Lacrimation (watery eyes), rhinorrhea (runny nose), pupillary dilation, and yawning. Piloerection (bristling of hairs) or gooseflesh is the origin of "cold turkey" for the abstinence syndrome. Males may exerience sweating and spontaneous ejaculation while awake. Morphine, heroin, and methadone withdrawal syndrome begins 6-8hrs after last dose following a period of at least a week of use. It reaches intensity during the 2nd or 3rd day then subsides. Meperidine (Demerol) withdrawal begins within 8-12hrs from abstinence and lasts about 5 days.

caffeine intoxication symptoms

Often occurs after recent consumption of caffeine usually at more than 250mg. Symptoms include restlessness, nervousness, excitement, agitation, rambling speech, and inexhaustibility. Physical symptoms include flushed face, diuresis, GI disturbances, muscle twitching, tachycardia, or cardiac arrythmias.

Stimulant intoxication symptoms

People feel superhuman while using stimulants. They feel elated, euphoric, and sociable. Unfortunately, they are also hypervigilant, sensitive, anxious, tense, and angry. Physical symptoms include two or more of the following: chest pain, cardiac arrhythmias, high or low blood pressure, tachycardia or bradycardia, respiratory depression, dilated pupils, perspiration, chills, nausea or vomiting, weight loss, psychomotor agitation or retardation, weakness, confusion, seizures, or coma.

Risk Factors: Environmental

Poverty raises the risk of unfavorable living environment, lack of parental supervision, poor educational resources, and impaired support systems. A cycle of negative environmental events often begins with disadvantaged neighborhoods, increasing stress and anxiety along with lack of or negative social ties, contributing to depression. Coping mechanisms may include drugs and acting out behaviors.

Inhalant intoxication symptoms

Small doses- disinhibition and euphoria. High doses- fearfulness, illusions, auditory and visual hallucinations, distorted body image; apathy, diminished social and occupational functioning, impaired judgement, and impulsive and aggressive behavior; nausea, anorexia, nystagmus, depressed reflexes, and diplopia. High doses and long exposure- stupor, unconsciousness, and amnesia. *Delirium, dementia, and psychosis are also serious side effects from inhalant use. **Sudden sniffing death due to cardiac arrhythmias may occur with inhalants, especially with butane and propane.

Scheduled 1 drugs are defined as?

Substance that have no accepted medical use & high potential for abuse. Examples include heroin and lysergic acid diethylamide (LSD).

Alcoholism risk factors: Environmental- Cultural

Substance use may create a sense of community and belonging in otherwise isolated individuals. The lifestyle of individuals who use substances may even seem alluring and dramatic to vulnerable people. In some cultures and religions, alcohol use is not accepted, and any use would be considered deviant. In other cultures, alcohol use is a regular part of everyday life, and the amount of consumption would be alarming to people outside the culture. Muslim-majority countries such as Pakistan, Libya, and Saudi Arabia have prohibitions against alcohol. In Afghanistan, it is illegal for citizens to purchase alcohol, but there are still places for foreigners to drink. In the United States, some Christian denominations such as Pentecostal, Baptist, and Mormon reject the use of alcohol.

inhalant intox tx

Usually does not require treatment. Serious and potentially fatal responses such as coma, cardiac arrhythmias, or bronchospasms do happen. A psychotic response can be induced by inhalant intoxication. Haloperidol (Haldol) may be required to manage severe agitation.

Hallucinogen intox treatment

Treatment for hallucinogens include talking the patient down; reassuring that the symptoms are caused by the drug and will subside. Patient and provider safety is essential. Physical restraints may be needed. In severe cases, antipsychotics such as haloperidol (Haldol) or a benzodiazepine such as diazepam (Valium) can be used in the short term.

opioid intoxication symptoms

psychomotor retardation drowsiness slurred speech altered mood impaired memory and attention bradycardia hypotension hypothermia meiosis (pinpoint pupils) intense drowsiness coma Skin disruptions in the form of track marks or fresh injection sites may confirm IV drug use.

Stimulant withdrawal symptoms

Withdrawal symptoms begin within a few hours to several days. Symptoms include tiredness, vivid nightmares, increased appetite, insomnia or hypersomnia, and psychomotor retardation or agitation. Functionality is impaired during this withdrawal process. Depression and suicidal thoughts are the most serious side effects of stimulant withdrawal

alcohol withdrawal delirium

aka delirium tremens (DTs) - medical emergency; can result in the death in 20% of untreated patients, usually as a result of medical problems such as pneumonia, renal disease, hepatic insufficiency, or heart failure. Alcohol withdrawal delirium may happen anytime in the first 72 hours. Autonomic hyperactivity may result in tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension. Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium. Delusions and hallucinations may result in unpredictable behaviors as patients try to protect themselves from what they believe are genuine dangers. Patients on any medical floor are at risk for this condition after cessation of heavy drinking for 3 days and are a danger to themselves and others. Serious physical illness such as hepatitis or pancreatitis may increase the likelihood of alcohol withdrawal delirium. It is rare to see this syndrome in individuals in good physical health. Prevention of alcohol withdrawal delirium is the goal. Oral diazepam (Valium) may be useful in the symptomatic relief of acute agitation, tremor, impending or acute DTs, and hallucinosis. Chlordiazepoxide (Librium) may keep your patient out of danger. Once delirium appears, intravenous lorazepam (Ativan) is used to treat these severe symptoms. Seclusion may be necessary. Dehydration, often exacerbated by diaphoresis and fever, can be corrected with oral or intravenous fluids

DSM-5 provides diagnostic criteria for the following psychoactive substances:

alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives (including hypnotics and antianxiety medications), stimulants, and tobacco.

Cannabis

comes from the dried leaves, flowers, stems, and seeds of the hemp plant, Cannabis sativa. A chemical, delta-9-tetrahydrocannabinol (THC), is responsible for its mind-altering effects. The concentrated form of cannabis is known as hashish. Synthetic cannabinoids of THC, dronabinol (Marinol) and nabilone (Cesamet), are prescribed to treat nausea caused by chemotherapy for cancer and boost appetite in patients with AIDS. The US Food and Drug Administration (FDA, 2018) also approved Epidiolex (cannabidiol, CBD) for rare forms of epilepsy. Unlike THC, CBD does not cause intoxication.

Caffeine overdose symptoms

fever, tachycardia or bradycardia, and hypertension followed by hypotension. Extremely high doses of caffeine may result in grand mal seizures and respiratory failure may cause death. Pupillary mydriasis (dilation), muscular rigidity and hyperreflexia, and n/v are common. Disorganized thinking, agitation, hallucinations and seizures due to ischemia from vasoconstriction.

Sedative, hypnotic, and antianxiety OD tx

gastric lavage, activated charcoal, and careful vital sign monitoring. Patients who are awake after overdosing should be kept awake to prevent a loss of consciousness. If unconscious, an intravenous fluid line should be established. An endotracheal tube may be required to provide a patent airway, and mechanical ventilation can be used if necessary

Cannabis intoxication symptoms

heightened senses, depersonalization, derealization, delirium. 2 of the following are required for diagnosis of cannabis intoxication: conjunctival injection (red eyes from vessel dilation), increased appetite, dry mouth, and tachycardia.

Scheduled 2 drugs

high potential for abuse, considered dangerous, and only available by rx. Examples include methadone, meperidine (Demerol), and methylphenidate (Ritalin).

Tobacco withdrawal symptoms

irritability, anxiety, depression, difficulty concentrating, restlessness, insomnia.

Schedule 5 drugs

low abuse potential; limited quantities of narcotics for treatment of diarrhea, coughing, and pain. No prescription needed for adults over the age of 18. examples include atropine/diphenoxylate (Lomotil), guaifenesin and codeine (Robitussin AC), and pregabalan (Lyrica), available OTC.

Caffeine

most widely used psychoactive drug in the world. Excessive caffeine use is not an official use disorder, however may result in intoxication, overdose and withdrawal. Excessive caffeine use is associated with psychiatric disorders including bipolar disorders, eating disorders, and sleep disorders.

hallucinogen intoxication symptoms

paranoia, impaired judgment, derealization, depersonalization, intensification of perceptions, illusions, hallucinations, pupil dilation, tachycardia, sweating, palpitations, tremors, blurred vision, incoordination

Sedative, hypnotic, and antianxiety intoxication

slurred speech, incoordination, unsteady gait, nystagmus, and impaired thinking. Coma is a dangerous possibility with this class of drugs. Inappropriate aggression and sexual behavior, mood fluctuation, and impaired judgment may also be side effects.

Inhalants

substances whose fumes are sniffed and inhaled to achieve a mind-altering effect. These include solvents for glues and adhesives propellants found in aerosol paint sprays, hair sprays, and shaving cream. Thinners, such as paint products and correction fluids Fuels, such as gasoline and propane.

opioid overdose

unresponsiveness, slow respiration, coma, hypothermia, hypotension, bradycardia Three symptoms - coma, pinpoint pupils, and respiratory depression are strongly suggestive of opioid overdose.

Alcohol intoxication

• 20 mg/dL (0.02 g/dL)—Two alcoholic drinks: Slower motor performance, decreased thinking ability, altered mood, and reduced ability to multitask. • 50 mg/dL (0.05 g/dL)—Three alcoholic drinks: Impaired judgment, exaggerated behavior, euphoria, and lower alertness. • 80 mg/dL (0.08 g/dL)—Four alcoholic drinks: Poor muscle coordination, altered speech and hearing, difficulty detecting danger, impaired judgment, poor self-control, and decreased reasoning. • 100 mg/dL (0.10 g/dL)—Five alcoholic drinks: Slurred speech, poor coordination, and slowed thinking. • 150 mg/dL (0.15 g/dL)—Six alcoholic drinks: Vomiting (unless high tolerance) and major loss of balance. • 200 mg/dL (0.20 g/dL)—Eight to 10 alcoholic drinks: Memory blackouts, nausea, and vomiting. • 300 mg/dL (0.30 g/dL)—More than 10 alcoholic drinks: Reduction of body temperature, blood pressure, respiratory rate, sleepiness, and amnesia. • 400 mg/dL (0.40 mg/dL)—Impaired vital signs and possible death. *Legal definition of intoxication in most states requires a blood concentration of 80-100mg ethanol per deciliter of blood (mg/dL).

PCP intoxication symptoms

• Belligerence, assaultiveness, impulsivity, unpredictability • Psychomotor agitation • Impaired judgment • Involuntary rapid eyeball movement • Hypertension • Numbness • Loss of muscle coordination • Problems speaking due to poor muscle control • Muscle rigidity • Seizures or coma • Exceptionally acute hearing • Perceptual disturbances Hyperthermia may also occur.