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)
