Substance Use Disorders

• a primary, chronic , neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations
• characterized by the 5C's

• chronicity
• control over use impaired
• compulsive use
• continued use despite harm
• craving

a state of adaption in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

state of adaptation that is manifested by ta drug class-specific withdrawal syndrome that can be produced by abrupt cessation or rapid dose reduction, decreasing blood levels of the drug and/or by administration of an antagonist

• a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 or more of the following, within a 12-month period:
• recurrent substance use resulting in failure to fulfill major role or obligations at work, school, or home
• recurrent substance use in hazardous situations
• recurrent substance-related legal problems
• continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effect of the substance

• 3 or more of the following present at any time during a 12-month period:
• tolerance
• withdrawal
• substance taken in larger amounts or over a longer period than originally intended
• persistent desire or unsuccessful efforts to cut down or control use
• great deal of time spent in activities in obtaining the substance, using the substance, or recovering from the substance's effects
• social, occupational, or recreational activities given up or reduced due to substance use
• substance use continued despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by the substance use

• health hazards (including walking, driving, etc.)
• acts of violence and/or crime
• impaired judgement and performance - reduced work productivity and performance
• economic burdon to the society

the mesocorticolimbic system

depressant

dose dependent effects

• opiates (euphoria)
• GABA
• glutamine
• dopamine

• 14g of pure alcohol:
• 12 oz beer
• 8-9 oz malt liquor
• 5 oz wine
• 1.5 oz of spirits (80 proof)

5-10 minutes in the stomach

• 30-90 minutes after the last drink, variable on many factors:
• weight
• stomach contents
• gender
• etc.

• > 90% in the liver (alcohol to acetaldehyde in cell to CO₂ and H₂O by alcohol dehydrogenase)
• < 10% excreted by the lungs, urine and sweat

• Cut down (have you ever wanted to cut down on your drinking?)
• Annoyed (if people talk about your drinking)
• Guilty (about your drinking
• Eye opener (do you need a morning drink?)

• assess vital signs, manage resp. depression or BP instability if present, minimize aspiration risk
• maintian in a safe and monitored environment; decrease external stimulation
• measure a BAC; usually measured in mg/dL in the hospital (120mg/dL = 0.12 BAC)
• assess for recent use of other substances that could complicate clinical course
• evaluate for signs/symptoms of withdrawal

• 0.02 - 0.03 = no loss of coordination, slight euphoria, adn loss of shyness
• 0.07 - 0.09 = slight impairment of balance, speech, vision, reaction time, and hearing. Euphoria. Judgement and self-control are reduced, and caution, reason, and memory are impaired. It is illegal to operate a motor vehicle in some states at this level.
• 0.10 - .0125 = significant impariment of motor coordination and loss of good judgement. Speech can be slurred; balance, vision, rxn time, and hearing impaired. Euphoria. It is illegal to operate a motor vehicle at this level of intoxication.
• 0.16 - 0.20 = Dysphoria(anxiety, resltlessness) predominates, nausea can appear. the drinker has the appearance of a "sloppy drunk".
• 0.3 = loss of consciousness
• 0.4 or higher = onset of coma, possible death caused by respiratory arrest

within 4-12h or cessation or reduction in alcohol use

• hand tremor
• agitation and anxiety
• irritability
• GI upset
• insomnia
• diaphoresis
• tachycardia
• autonomic hyperactivity
• hallucinations
• seizures
• DT's

• Delirium Tremens:
• intense acute withdrawal characterized by delirium, tremor, tachycardia, hyperthermia
• has been described as "clouding of the consciousness"
• potentially life-threatening

• benzodiazepines:
• Chlordiazepoxide
• Diazepam
• Lorazepam
• Oxazepam
• Temazepam
• Respiril
• all are equally effective
• some are better for certain scenarios though (active/severe liver disease....BZDs are metabolized by the liver)

• Symptom-triggered therapy:
• administer CIWA-Ar q h to assess need for meds
• score 10 or more, administer meds such as chlordiazepoxide 50-100mg or lorazepam 2-4mg
• Fixed-schedule therapy:
• May administer q 6-8h
• provide additional meds prn when sx are not controlled
• advantage is nurse knows when to administer
• disadvantage is too much/too little meds being given

cocaine is an alpha and beta stimulant. If you block beta, you get excessive alpha stimulation

• CBZ
• VPA
• clonidine
• propranolo
• neuroleptics
• barbiturates
• gabapentin
• topiramate

• replace fluids if dehydrated (avoid overhydration)
• replace electrolytes if indicated
• replace thiamine (often depleted in alcoholics) - 100mg x 3-5d (should be given prior to dextrose administration which can deplete it more)
• replace other vitamins and folic acid as necessary

• Wernicke's encephalopathy (memory loss)
• Korsakoff's psychoses (fill in holes in memory with fantasy)

• esophagitis
• PUD
• fatty liver
• alcohol-induced hepatitis
• cirrhosis
• acute or chronic pancreatitis
• HTN
• cardiomyopathy
• CAD
• Wernicke's encephalopathy
• Korsakoff's syndrome
• peripheral neuropathy
• seizures
• thrombocytopenia
• anemia
• sexual dysfunction
• sleep disorders
• vit B deficiency
• peripheral myopathy
• certain cancers

• acamprosate (reduce craving)
• naltrexone (reduce craving)
• disulfiram (causes emesis)

• cocaine HCl
• cocaine base (crack, rock - produced by alkalinizing with NaHCO₃)

• inhalation - seconds, 10-15 min high
• snorting - minutes, 20-30 min high
• injection

• motor agitation
• elation
• euphoria
• grandiosity
• hypervigilance
• sweating or chills
• N/V
• pruritis of the nose

• tachycardia
• mydriasis
• abnormal BP
• arrhythmias
• cardiac arrest
• resp. depression

• fatigue
• sleep disturbances
• nightmares
• depression
• changes in appetite

• benzoylecgonine
• detected for 12-72h after use (1-3weeks with prolonged/heavy use)

• cocaine + alcohol = cocaethylene (more potent)
• cocaine + heroin = speedball

• ABC's
• tx of hyperthermia, seizures and agitation if present (e.g. BZD)
• management of cocaine-induced cardiovascular complications if present

• chest pain
• dyspnea
• diaphoresis
• palpitations
• dizziness
• nausea

• ECG
• cardiac markers
• stress test

• ASA, BZD
• IV nitro, nitroprusside (or phentolamine) for persistent HTN
• AVOID BBL in acute setting (excessive alpha stimulation results if only block beta effects of cocaine)
• CCB if not responsive to BZD or nitro

acamprosate (if CrCl is not over 30 mL/min)

• disulfiram
• naltrexone

ER naltrexone (Vivitrol) as a deep IM gluteal injection

• euphoria
• dysphoria
• apathy
• motor retardation
• slurred speech
• attention impairment
• miosis

3 weeks

• Naloxone 0.4-2mg IV q 3 min and support vital fx
• if more than 10mg is req'd, investigate other causes

yes

no

heroin

several months of steady use

1-3d after last dose

8-14h after last dose

3-4h after last dose

to temporarily use long-acting opioids to reduce the severity of w/d to short-acting opioids

methadone, buprenorphine (with or without naloxone), clonidine

Methadone, buprenorphine (with or without naloxone), Naltrexone, clonidine

• if admitted to the hospital for non-withdrawal illness
• for 3d in outpatient setting until pt is accepted into a licensed methadone tx program

if the doctor recieved training and a waiver to practice opioid addiction tx

yes, but only 5-10mg

yes, should write "for chronic pain" on the script (no X in DEA#, training, or waiver req'd to prescribe for pain)

• yes, it can be used by addicts to bridge the gap b/w their regular opioid usage
• the naloxone will only cause w/d if it is injected

• 1-800-BUP-CSAT
• info@buprenorphine.samhsa.gov

• muscle relaxants
• NSAIDs
• antiemetics
• antidiarrheals
• sleep meds
• vistaril
• gabapentin
• drugs for nicotine/alcohol w/d

methadone

• pure opioid receptor antagonist
• can cause w/d if pt has recent opioid use (usually started 7-10d after pt begins tx to avoid this)
• for maintenance tx only

• alpha agonist
• helps with anxiety
• shortens duration of w/d sx
• normalizes neurochemistry to make pt less addicted
• helps facilitate methadone w/d

• typically higher dosing than used for HTN
• potential for hypotension
• taper off to prevent rebound HTN

• antihistamine
• similar to clonidine
• reduces anxiety and GI sx
• OFF-LABEL use