Substance Related Disorders - Psychiatry - Lecture Slides, Slides of Psychology

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Substance Related Disorders Docsity.com Substance Disorders • Substance Intoxication • Substance Withdrawal • Substance Induced Psychotic Disorder • Substance Induced Mood Disorder • Substance Induced Anxiety Disorder • Substance Induced Sleep Disorder • Substance Induced Delirium • Substance Induced Persisting Dementia • Substance Induced Persisting Amnestic Disorder • Substance Induced Sexual Dysfunction Docsity.com Other costs of addiction • 40% of hospital admission have drug/ETOH as a factor • 25% of all deaths! • 100,000 deaths/year from drug/ETOH • Intoxication is associated with 50% of all MVAs, 50% of all DV cases and 50% of all murders Docsity.com Phenomenology:intoxication • Intoxication: a specific syndrome of maladaptive behavioral or psychological changes due to the recent ingestion of or exposure to a substance that acts of the CNS Docsity.com Substances inducing intoxication identified in the DSM IV • Alcohol • Amphetamines • Caffeine • Cannabis • Cocaine • Hallucinogens • Inhalants • Opiates • Phencyclidine • Sedatives/hypnotics/7a nxiolytics • Residual category (steroids, nitrous oxide) Docsity.com Tolerance • The need to use a greatly increase amount of a substance in order to achieve the desired effect OR • A markedly diminished effect being associated with continued use of the same amount of the substance • The degree to which tolerance develops varied greatly between drugs Docsity.com Withdrawal • Maladaptive behavioral change with physiological & cognitive effect that occurs • when concentration of a substance declines in the body Docsity.com Substance Abuse a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following 1. Failure to fulfill role obligations or poor work performance. 2. Use on hazardous situations 3. Substance related legal problems 4. Persistent or recurrent social or interpersonal problems • And never met criteria for dependence Docsity.com Substance Dependence Course Specifiers • Early remission- no criteria met for > 1 month and <12 months • Sustained remission - no criteria met for > 12 months • Partial remission- occasional criteria met • Full remission- no criteria met Docsity.com Learning and Physiological Basis for Dependence • Reinforcing behaviors / Pleasure Circuit/ reward circuit/ hippocampal and limbic memory circuit • acute increases of levels of neurotransmitters in the brain • Ex. Increased Dopamine (DA) in the limbic areas (ventral tegmental DA neurons synapsing on the nucleus accumbens neurons is very rewarding. • Some drugs also increase serotonin and/or norepinephrine. Docsity.com Learning and Physiological Basis for Dependence • After using drugs or when stop – leads to a depleted state resulting in dysphoria and/or cravings to use, reinforcing the use of more drug. • Response of brain cells is to downregulate receptors and/or decrease production of neurotransmitters that are in excess of normal levels. Docsity.com 2. Treat the Medical Complications -Detoxification- oupt, "social detoxification" program, inpt with close medical care -Address associated medical complications: dehydration, malnutrition, DT's, seizures, pneumonia, cardiomyopathy, etc Docsity.com Options for where to treat • Hospitalization- -Due to drug OD, risk of severe withdrawal, medical comorbidities, requires restricted access to drugs, psychiatric illness with suicidal ideation • Residential treatment unit -Do not require intensive medical / psychiatric monitoring -Require a restricted environment -Partial hospitalization -Step down unit • Oupt Program -No risk of med/ psych morbidity/ highly motivated pt Docsity.com 3. Address Comorbid Psychiatric Conditions 50% pf people with SRD have another mental disorder 4. Address Internal & External Reinforcers Group, individual, family therapy/ educations counseling, AA Docsity.com SPECIFIC SYNDROMES: ALCOHOL- CNS depressant Intoxication- clinical s/s • BAL (blood alcohol level) 0.08 or 1.0 g/dl- legal definition • Mood lability, impaired judgment, ataxia. At higher doses see nystagmus, slurred speech, decreased concentration, anterograde memory loss "blackouts". Docsity.com Alcohol Withdrawal • Early on sx of anxiety, irritability, tremor, decreased con, insomnia, N/V etc • As withdrawal continues, increased risk of delirium tremens (confusion, alternating level of consciousness, hallucinations, HTN, tachycardia, diaphoresis, vascular collapse) and seizures. DTs usually appear withing 72 hours after stopping. • Seizures within 48-72 hrs Docsity.com Alcohol Withdrawal cont. • CIWA (Clinical Institute Withdrawal Assessment for Alcohol) • Assigns numerical values to things such as orientation, N/V, tremor, sweating, anxiety, agitation, tactile/ auditory/ visual disturbances and HA. VS checked but not recorded. Total score of > 10 give meds and re check in 1 hour. (Checks but does not score VS) Docsity.com Medications to treat ETOH dep Disulfiram ( antabuse) 250mg – 500mg po qd • Inhibits aldehyde dehydrogenase and dopamine beta hydroxylase • Aversive reaction when alcohol ingested- vasodilatation, flushing, N/V, hypotenstion/ HTN, coma / death • Hepatotoxicity check LFT's and h/o hep C • Neurologic with polyneuropathy / paresthesias that slowly increase over time and increased risk with higher doses • Psychiatric side effects with psychosis, depression, confusion, anxiety • Dermatologic rashes and itching • Watch out for disguised forms of alcohol- cologne, sauces, mouth wash, OTC cough meds, Nyquil, alcohol based hand sanitizers, etc Docsity.com Medications to treat ETOH dep cont. Naltrexone 50mg po qd • Opioid antagonist thought to block mu receptors reducing intoxication euphoria and cravings • Hepatotoxicity at high doses so check LFT's Acamprosate( Campral) 666mg po tid • -Unknown mech of action but thought to stabilize neuron excitation and inhibition, may interact with GABA and Glu receptor, cleared renally Docsity.com Benzodiazepine( BZD)/ Barbiturates Intoxication similar to alcohol but less cognitive / motor impairment • variable rate of absorption into the CNS (lipophilic), onset of action and duration • the more lipophilic and shorter the duration of action , the more " addiction " they can be • all can by addicting Docsity.com OPIOIDS Drugs that bind to the mu receptors in the CNS to modulate pain • Intoxication- pinpoint pupils, sedation, constipation, bradycardia, hypotension and decreased respiratory rate • Withdrawal- not life threatening unless severe medical illness, but extremely uncomfortable. s/s dilated pupils lacrimation, goosebumps, n/v, diarrhea, myalgias, arthralgias, dysphoria or agitation • Rx- symptomatically with antiemetic, antacid, antidiarrheal, muscle relaxant such as methocarbamol, NSAIDS, clonidine and maybe BZD • Neuroadaptation: increased DA and decreased NE Docsity.com Treatment for Opiate dependence CD tx including support, education, skills building, NA , opiate substation Medications • Naltrexone 50mg po qd Opiate blocker, mu antagonist Methadone for opiate substitution therapy Mu agonist Start at 20-40mg and titrate up until not craving or using illicit opioids Average dose 80-100mg qd Pt needs to be enrolled in a certified opiate substitution program Docsity.com Treatment for Opiate dependence cont. • Buprenorphine -Partial mu agonist/ antagonist; low doses act as an agonist with pain control; at higher doses no increased effect (less risk of OD) and may behave like an antagonist (can trigger withdrawal) -Any physician can rx after taking certified ASAM course -Helpful for highly motivated people who do not need high doses Docsity.com Cocaine • Route nasal, IV or smoked • Has vasoconstrictive effects that may outlast use and increase risk for CVA and MI (obtain EKG) • Can get rhabdomyolsis with compartment syndrome from hypermetabolic state • Can see psychosis associated with intoxication that resolves • Neuroadaptation: cocaine mainly prevents reuptake of DA Docsity.com Treatment of Cocaine Dependence • CD treatment including support, education, skills CA • Disulfiram (Antabuse) 250mg po qd may be helpful for cravings by inhibiting dopamine- beta-hydroxylase, increasing CNS dopamine levels Docsity.com Amphetamines (dexadrine, amphetamine, methamphetamine, crystal, ice) • Similar intoxication syndrome to cocaine but usually longer • Route- oral, IV, nasally, smoked • No vasoconstrictive effect • Chronic use results in neurotoxicity possibly from glutamate and axonal degeneration • Can see permanent amphetamine psychosis with continued use • Treatment similar as for cocaine but no known substances to reduce cravings • Neuroadaptation: Amphetamines inhibit the reuptake of DA, NE, SE and greatest effect by increased release of DA Docsity.com NICOTINE cont. • Nicotine intoxication- abd pain, dizziness, HA, N/V, palpitations; self limited • Neuroadaptation: nicotine acetylcholine receptors on DA neurons in ventral tegmental area release DA in nucleus accumbens • Biphasic effect • Tolerance Rapid • Withdrawal- dysphoria, irritability, anxiety, decreased concentration, insomnia, increased appetite/ wt gain, cravings Docsity.com Treatment for Nicotine • Cognitive Behavioral therapy • Agonist substitution therapy- nicorette gum, transdermal patch, nasal spray • Medication: bupropion( Zyban) 150mg po bid Docsity.com HALLUCINOGENS • Naturally occurring- Peyote cactus( mescaline)/ Magic Mushroom( Psilocybin) • Synthetic agents - LSD, lysergic acid diethyamide- oral • DMT, dimethyltrptamine- smoked, snuffed, IV • STP,2,5-dimethoxy 4-methylamphetamine –oral • MDMA , 3,4-methyl-enedioxymethamphetamine, ecstasy (XTC)-oral Docsity.com CANNABIS • Most commonly used illicit drug in America • THC levels reach peak 10-30 min, lipid soluble; long half life of 50 hours • Intoxication- subtle/ appetite and thirst increase Colors/ sounds/ tastes are clearer Increased confidence and euphoria Relaxation Increased libido Transient depression, anxiety, paranoia Tachycardia, dry mouth, conjunctival injection Slowed reaction time/ motor speed Impaired cognition Psychosis Docsity.com CANNABIS cont. • Neuroadaptation- CB1, CB2 cannabinoid receptors in brain/ body • Coupled with G proteins and adenylate cyclase to CA channel inhibiting calcium influx • Neuromodulator effect; decrease uptake of GABA and DA • Cannabis withdrawal not listed in DSM but can occur with insomnia, irritability, anxiety, poor appetite, etc Docsity.com CANNABIS cont. • Cannabis dependence can lead to "amotivational syndrome" • Treatment -Detox and rehab -Behavioral model -No pharmacological treatment but may treat other psychiatric symptoms Docsity.com