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Substance Use Disorders - Coggle Diagram
Substance Use Disorders
Physiology
Reward Pathway
All drugs of abuse target brain's reward syndrome by increase dopamine, and when activated
Presentation
Adolescents
Concurrent anxiety or mood disorders, difficult to differentiate experimentation to more serious issue, changes in school performance, illegal activities, unexplained weight loss
Adults
Many red flag, ED visits, missed work, legal issues, depression,w eight loss, fatigue, family issues
Elderly
2 types
Those with lifelong pattern of abuse
Those who develop substance abuse for first time later in life
Strong indicator is continuation of substance after warnings to stop for medical/cognitive reaqsons
Alcohol Use disorder
Epidemiollogy
Highest among individuals 18-29, and greater among men than among women
CAGE Questionnair
Questions
People annoyed you by critizing your drinking
Felt you should Cut down?
Felt guilty about drinking?
Drink first thing in the morning
Results
Items are scored 0 or 1, and total of 2< is considered significant
DSM 5 Alcohol/Benzodiazepine Intoxication
Recent Use of substrance
Clinically significasnt amladaptive behavriioual os psychological changes that developed during or shortly after use
One+ of the following sings/symptoms, during or shortly after use
Slurred speech, incooridnation, Unstead gait, Nystagus, Impariment in cognition, Stupor or Coma
Signs
Signs and symptoms not attributable to any other medical condition/mental disorder
DSM 5 Alcohol/Benzodiazepine Withdrawal
Cessation of substance use that has been prolonged
2+ of the following develop within hours to days of cessation
Autonomic Hyperactivity, increased hand tremor, insomnia, Nausea/Vomiting, Transient visual,tactile, or auditory hallucinations, psychomotor agitation, anxiety, grand mal seizures
Signs and symptoms in Criberia B that cause clincially significant distress/social impairment
Signs and symptoms not attributable to any other mental disorder
Course of Withdrawal
4-12 hours onset peaks at 24-48 hours, resolves in 5-7 days
Symptoms serve to perpetuate ongoing drinking
Increased severity of withdrawal
Increase quantity and frequency of consumtpion, prior history of ED visit, previous alcohol withdrawal seizures, previous history of delirium, FHx of alcohol withdrawal, midcal conditions, current benzo conmsumption
Preventable Complications of Alcohol Withdrawal
Alcohol Withdrawal zeizures
Treated wtih IV diazepam
Delirium
Treated with diazepam
Treatment of Withdrawal
General
Alleviate symptoms, prevent progression of symptoms, treat comorbities
Management
Benzodiazepines, Gabapendim (off label)
Thiamine
Off label to prevent wernick encephalopathy and korsakoff syndfrome
CIWA-Ar Score
Criteria
Nausea/Vomiting, Agitation, Tremor, Tactile disturbances, paroxysmal sweats, auditory disturbances, anxiety, headache, visual disturbances, orientation
Score
0-9: Absent-minimal withdrawal, 10-19 mild-moderate withdrawal, >20 severe withdrawal
Harm REduction Strategies
Delay use until later in day, decrease strength, pace use, plan days of no alcohol use, only buy what you intend to consume,
Anticraving Medication
First line (Naltrexone, Acamprosate)
Principles: Titrate dose until cravings are mild and patient is achieving goals
Diagnosis
2 or more of the following in the past 12 monhts
Impaired control, social impairment, risky use, pharmacological criteria
Sedative-Hypontic, Anxiolytic use disrrder
Dangers of Benzodiazepines
Confusion/worsening dementai, MVA, OD, decrease respiratory drive, sleep apnea
DSM 5 Sedative hypotic or anxiolytic intoxication
Recent SUbstance Use
Clinically significant maladtaptive behavioural or psychological changes
1+ of the following signs/symptoms following or during use
Slurred speech, incoordination, unsteady gait, nystagmus, impairment in cognition, Stupor or coma
Signs/symptoms not attributable to another condition
Physical dependent on Benzo
State of adaptation that can be manifested by withdrawal syndrome from abrupt cessation of dose
DSM Sedative-Hypontic, Anxiolytic use disrrder Withdrawal
INcrease severity
More severe with higher daily doses, benzo with short half-lives and longer durations of use
Criteria
Cessation of substance use that has been prolonged
2+ following developing within hours ot a few days after cessation
Autonomic hyperactivity, increased hand tremor, insomnia, nausea/vomiting, transient visual/tactile/auditory hallucinations or illusions, psychomotor agitation, anxiety, grand mal seizure
Signs and symptoms from criteria B causeing clinically significant distress or impairment in social occupational
Sings and symptoms not attributable to other medical condition
Symptoms
anxiety, insomnia, restlessness, agitation, irritability, muscle tension, nausea, diaphoresis
Pharamcological Taperse
Diazepam equivalent to taper, <50 outpatient, 50-100 mg inpatient
Challenges
Recurrence of original disorder, rebound symptoms, withdrawal
Opioid Intoxication
DSM 5 Opioid Intoxication
Criteria
Recent use of opioid
Clinically significant problematic behaviour during or shortly after use
Pupillary constrition and one of the following
Drowsiness/coma, slurred spech, memory/attnetion impairment
Signs and symptoms not attributable to other medical condition
COurse and Progress
Symptoms last for several hours, and severe intoxicatipon lead to overdose
Inccreased risk of overdose
Non-tolerance combined with other depressnats
DSM opioid withdrawal
Criteria
Either
Cessation of or reduction of opioid use that has been heavy and prolonged
Administration of an opioid antagonist after a period of opioid use
3+ of the following in minutes to days aftter criteria A
Dysphoriic mood, nausea or vomiting, muscle aches, lacrimation or rhinorrhea, pupillary dilatioon, diarrhea, yawning, feer, insomnia
Signs and symptoms in B causing significant distress or impairment
Signs or symptoms that do not indicate another medicaiton
Course and Prognosis
Onset 6-12 hours to 2-4 days peak 2-3 days, duration 5-10 days, not life threatening to most
Treatmetn
Buprenorphine acts as a partial opioid agonist
Naloxone acts as a competitive opioid antagonist
Treatment
First line with Buprenorphone/naloxone
Transition to methadone (synthetic opioid agonist)
Stimulant Intoxication
DSM 5 Stimulant Intoxication
Recent use of amphetamine-type substance, cocaine, or other stimulant
Clinically significant problematic behavioural or psychological changes that developed during or shortly after use of a stimulant
2+ of the following signs/symptoms
Tachycardia or Bradycardia, Pupilary dilation, elevated or lowered blood pressure, perspiration or chills, nausea or vomiting, evidence of weight loss, psychomotor agitation or retardation, muscular wekness, respiratory depression, confusion/seizures/dyskinesias
Signs and Symptoms not attributable to another medical condition, mental disorder, or intoxication with another substance
DSM 5 Withdrawal
Cessation of prolonged amphertamine-type substance, cocaine or other stimulant use
Dysphoric mood and two+ of the following changes
Fatigue, Vivid, unpleasant dreams, insomnia or hypersomnia, increased appetite, psychomotor retardation
Sigsn and symptoms cause clinically significant distress and impairment in social/occupational or other important areas of functioning
Signs + Symptoms not attributable to another cause of functioning
Cannabis
Description
THC is principal psychoactive ingredient - amount in a sample can vary greatly
Can easily deposit in fat stores, and can take months -> years to clear from fatty tissue from the brain
withdrawal signs and symptoms are not as dramatic
DSM 5 Intoxication
Recent use of cannabis
Clinically significant problematic behaviour or psychological changes
Two of the following sings or symtpoms developing within 2 hrs of cannabis use
Conjunctival injection, increased appetite, dry mouht, tachycardia
Signs and symptoms are not attributable to another medical condition
DSM 5 Withdrawal
Cessation of cannabis use that has been heavy and prolonged
3+ signs and symptoms develop within approximately 1 week
Irritability/anger/aggression, nervousness/anxiety, sleep difficult, decreased appetite or weight loss, restlessness, depressed mood, and 1 of the following (abdominal pain, shakiness/tremors, sweating,fever, chills, or headache)