DR TIN NGO -MINH, R4PSYCHIATRYAPRIL 2010

B2B – Substance use

MCC Objectives

Stimulant – Depressants - Volatile Inhalants toxidromes Need for emergency care b/c of withdrawal SSx or other

complications LFTs and tests if suspected of ETOH abuse CAGE Alcohol withdrawal management, indications and

contraindications for disulfiram, and naltrexone, methadone; outline management of withdrawal from opioids and benzodiazepines

Outline management for stopping nicotine including advice to quit, nicotine replacement therapy, setting quitting dates, behavioral counseling, information about community resources Discuss guidelines for safe prescription writing for

benzodiazepines and opioids. Outline management of cardiovascular complications of cocaine

and alcohol. Outline prevention, detection, and management of infectious

complications of IV drugs use including Hepatitis B, C, and HIV.

Definitions

Abuse: maladaptive use x at least > 1year causing at least 1: failure to fulfill major role obligations (work, school,

home etc); Interpersonal problems Legal problems Physical health at risk while using (DWI, etc)

Dependence: maladaptive use at least > 1year causing at least 3: Tolerance Withdrawal takes more than intended

Definitions

Dependence (con’t) Desire or unsuccessful attempt to cut down or control + time spent obtaining, using, recovering Important social, occupational, recreational activities:

given up or reduced Continued use despite knowledge of physical or

psychological problem

CAGE Do you think you have a problem with ETOH use?

CAGE – Screening dependence

Have you ever tried to cut down in your drinking?

Have you ever been annoyed about criticism of your drinking?

Have you ever felt guilty about your drinking?

Have you ever had a morning eye opener?

Positive answer to >1 increases suspicion for ETOH dependance

Sensitivity 86%; Specificity 93%

Definitions

Intoxication: reversible syndrome causing behavioral or psychological changes due to a recent use memory, orientation, mood, judgment and level of functioning

Withdrawal: syndrome due to cessation or reduction of a heavy or prolonged use causing significant problems in social, occupational or other areas of functioning

Tolerance: phenomenon in which, after repeated administration, a given dose of a substance produces a decreased effect

Cross tolerance: ability of one drug to be substituted for another each usually producing the same physiologic and psychological effects

Alcohol

Peak blood concentrations in 30-90 minsRapid consumption and consumption on an empty

stomach enhance absorption and decrease time to peak blood levels

Intoxication more pronounced as blood levels are rising

90% metabolized by hepatic oxidationBody metabolizes approx one moderately sized drink

per hour (ie one 12 oz beer, 4 oz wine, 1 oz liquor) Cultural: Asians show increased acute toxic effects,

Native Americans and Inuit have higher rates

ETOH

Epidemiology: ETOH abuse: 7-10% of general pop; 20-40% hospitalized patients Involved in 30% of suicides; life time risk of suicide in alcoholics: 2-3.5%

(50-120x more than general pop) 33% of alcoholics have at least 1 parent with alcoholism; 50% have at least 1

other family member with alcoholism Child with 1 parent with ETOH dep: 25% risk of having the dz; 2 parents:

50% 33% with ETOH abuse have MDE

50% resolution after cessation of ETOH Pattern: men: ETOH MDE; women MDE ETOH

Associated with: Intox, withdrawal, Wernicke-Korsakoff syndrome, cerebral atrophy –

dementia, cerebellar degeneration, polyneuropathy, myopathy, GI (75% of pancreatitis pt have ETOH dependence), hepatitis, cirrhosis, GI cancer, gastritis, esophagitis…; HTA, thrombocytopenia, anemia, + MVC, trauma, dehydration, seizures, decrease albumin, B12, folate, anxiety, depression, sexual dysfunction, sleep disorder, psychosis, etc

Alcohol/benzodiazepine/barbiturate

Intoxication (1) Slurred speech Incoordination Unsteady gait Nystagmus Impaired attention

or memory Stupor or coma

• Withdrawal (2)• Autonomic

hyperactivity• Tremor• Insomnia• N/V• Hallucinations• Psychomotor agitation• Anxiety• Grand mal seizures

Alcohol Withdrawal

5% have SSx 6-48hrs after stopping ETOH Reguliar use, symptoms of withdrawal between doses. Chronology:

a) (8hrs) tremor, insomnia, nausea, tachycardia b) (2days) diaphoresis, anxiety, agitation, + HTA, headache,

hypervigilance c) abn VS, DT, hallucinations, disorientation

Symptoms: delirium, marked autonomic hyperactivity (tachycardia, sweating, agitation, anxiety), vivid hallucinations, agitation tremor, fever, seizures

Potentially letal: DT in 1% At risk: abn LFTs, old age, medical complications, hx of DT,

tolerance

ETOH/Benzo/sedatives

Acute treatment of withdrawal: Benzodiazepine – reach a level of sedation, then gradual

tapering Valium j1- 10-20mg TID, j2: 10-20mg BID; j3 10-20mg DIE ; or

other Benzo Thiamine 100mg

Thiamine before glucose multivitamine, folic acid Hydratation Monitor vitals, decrease stimulation CIWA –Ar scale

Treatment of dependance 12 steps, AA Antabuse (disulfiram), naltrexone?

Treatment of the underlying MDE?

Equivalence: Lorazepam (ativan) 1mg Clonazepam (Rivotril) 0.5mg Diazepam (Valium) 10mg Oxazepam (Serax) 20mg Alprazolam (Xanax) 0.5mg

Treatment of OD: flumazenil – caution…Other options for insomnia

Zopiclone? Benadryl? - Amytryptiline, buspirone, trazodone…

Recommended temporary use of benzos

Alcohol induced amnestic disorder

Wernickes encephalopathy: Reversible acute syndrome caused by thiamine deficiency (nystagmus, ataxia, confusion, 6th CN – lateral rectus). Treat with thiamine 100mg IM then PO

Korsakoffs syndrome: chronic condition result of thiamine deficiency, amnesia, confabulation, disorientation, polyneuritis, Rx with thiamine, 25% patients fully recover

Cocaine/amphetamine

Intoxication (2) Tach or bradycardia Mydriasis Elevated or lowered BP Chills or perspiration N/V Weight loss Psychomotor agiation or

retardation Muscle weakness, resp

depression, CP, arrythmia

Confusion, seizure, dyskinesias, dystonias or coma

• Withdrawal(2) CRASH• Fatigue• Vivid and unpleasant

dreams• Insomnia or

hypersomnia• Increased appetite• Psychomotor

agitation or retardation

Cocaine

Most commonly used in 18 to 25 year old range

Male to female ratio of 2:1Delusions and hallucinations may occur in

50% of those who use

Cocaine/amphetamine

Usually « binge » useAt a small dose:

Increase in BP, tachycardia, tachypnea, mydriasisAt a larger dose:

Arrythmia, seizures, stroke, resp depression, deathCRASH: craving, depression - anhedonia,

hypersomnia, + appetiteMedical problems: STDs, pulmonary dz…Psychosis: delusion, hallucinations, stereotypies

Antipsychotic: haldolRapid development 0f toleranceSexual dysfonctionTraitement: supportive, vaccine?

Opioids

Intoxication Myosis

And (1) Drowsiness or coma Slurred speech Impairment of

attention or memory

• Withdrawal (3)• Dysphoric mood• N/V• Muscle aches• Lacrimation or Rhinorrhea• Mydriasis, piloerection or

sweating• Diarrhea• Yawning• Fever• insomnia

Opioids

Associated with abuse mostlyMale to female ratio is 3 :1Most users in their 30s and 40s

Natural derivatives of opium: codeine, morphine

Synthetic opioids: methadone, oxycodone, dilaudid, talwin, demerol

Semisynthetic opioids: heroin

Opioids

Half life of heroin is a few minutes vs methadone: 20hrs Heroin: withdrawal ssx after ½ day, max after 2-3days Methadone: withdrawal after 36hrs max after 5days

Tolerance and withdrawal syndrome after 3 weeks of useVery unpleasant withdrawal: chronology:

« craving » Physical SSx: diaphoresis, rhinorrhea, lacrimation, yawning Irritability, mydriasis, loss of appetite, piloerection (after 1 day) diarrhea, N/V, fever, spams, insomnia, abd pain

Treatment of withdrawal: clonidine 0.1-0.2mg q4-6h; methadone?

Intoxication: Respiratory depression (+ is associated with other sedatives) Rx: naloxone 0.1-0.5mg q3-5min

Cannabis

Intoxication (2) Conjonctival

injection Increased appetite Dry mouth tachycardia

• WithdrawalNot in the DSM- Insomnia- Loss of appetite- Irritability- Diaphoresis -

tremor

Cannabis

5% lifetime useHighest among 18-21 y.o.Euphoric effects appear within minutes, peak at

30 mins and last 2-4 hoursMotor and cognitive effects can last 5 to 12 hoursPossible sensitizationMood d/o – self medication?Amotivationnal syndrome Increase risk of other drugs abusePossible indication for glaucoma, cancer/HIV –

nabilone

Hallucinogens

Psilocybin (mushrooms), mescaline, MDMA (ecstasy), LSD

Act as sympathomimeticsCause hypertension, tachycardia, hyperthermia

and dilated pupilsTolerance develops rapidly and remits within

several days of abstinencePhysical dependence and withdrawal do not occurOften contaminated with anticholinergic drugsPanic reactions (bad trips)Duration variable (shrooms 4-6 hrs, LSD 6-12 hrs)

Phencyclidine (PCP)

“angel dust”A dissociative anaesthetic and hallucinogenCommonly causes paranoia and violenceMay remain detectable in urine up to a weekAssociated with 3% substance abuse deaths

PCP

Effects are dose dependentAt low doses acts as a CNS depressant, with

nystagmus, blurry vision, incoordinationAt moderate doses hypertension, dysarthria,

ataxia, muscle rigidityAt high doses agitation, fever,

rhabdomyolysis, renal failure

Inhalants

Volatile hydrocarbons inhaled for psychotropic effect

eg gasoline, kerosene, laquers, paint thinner, fingernail polish remover

Typically abused by adolescent males of low SEC groups

Inhalants: Intoxication

Mild euphoria, belligerence, assaultiveness, impaired judgment

Ataxia, confusion, slurred speech, decreased reflexes, nystagmus

Can go on to delirium and seizuresLonger term risk of brain injury, liver

damage, bone marrow depression, peripheral neuropathies, immunosuppression

Urine toxicology

Alcohol: 7-10 hrsBenzodiazepine : 3 daysCocaine : 6-8 hrs (metabolites 2-3days)Marijuana: 3 hrs to 4 weeksCodeine: 48 hrsHeroin: 36-72 hrs

MCQs

Neuropsychological effects of hallucinogensmay include all of the following EXCEPT:

a) miosisb) tremorc) hyper-reflexiad) incoordinatione) blurred vision

Cocaine withdrawal can include all of thefollowing EXCEPT:

a) Crash sleepb) anergiac) anhedoniad) euphoriae) continued craving

Alcohol withdrawal includes all of thefollowing EXCEPT:

a) autonomic hyperactivityb) tremorc) starts within 2-4 hours after prolonged drinkingd) nauseae) irritability

A 30 year-old man presents in emergency with right lower quadrant abdominal pain. His wife reports that he had been drinking heavily in response to marital problems and had never had such pain before. Appendicitis was diagnosed and an appendectomy was successfully performed. Four days later the patient was anxious, restless, unable to sleep and claimed his wife was a stranger trying to harass him. The likeliest diagnosis is:

a) paranoid reactionb) delirium tremensc) maniad) schizophreniform reactione) post-operative delerium

Which of the following is best treated with high dose benzodiazepines:

a) schizophrenia, catatonic typeb) major depressionc) generalized anxiety disorderd) delirium tremense) psychogenic amnesia

A thorough assessment for the presence/absence of alcohol withdrawal should include questions about all of the following EXCEPT:

a) nausea and vomitingb) moodc) difficulty walking (ataxic gait)d) visual disturbancese) tremulousness

Sources

Toronto Notes and MCC Practice Exams 2003MCC Self-Administered Evaluating

Examination - Online