B2B – Substance use
DR TIN NGO-MINH, R4
PSYCHIATRY
APRIL 2010
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
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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:
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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:
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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
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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?
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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
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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 mins
 Rapid consumption and consumption on an empty stomach
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enhance absorption and decrease time to peak blood levels
Intoxication more pronounced as blood levels are rising
90% metabolized by hepatic oxidation
Body 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%
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33% with ETOH abuse have MDE
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50% resolution after cessation of ETOH
Pattern: men: ETOH  MDE; women MDE  ETOH
 Associated with:
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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
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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
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 Symptoms: delirium, marked autonomic hyperactivity
(tachycardia, sweating, agitation, anxiety), vivid
hallucinations, agitation tremor, fever, seizures
 Potentially letal: DT in 1%
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At risk: abn LFTs, old age, medical complications, hx of DT,
tolerance
ETOH/Benzo/sedatives
 Acute treatment of withdrawal:
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Benzodiazepine – reach a level of sedation, then gradual tapering
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Thiamine 100mg
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Valium j1- 10-20mg TID, j2: 10-20mg BID; j3 10-20mg DIE ; or other
Benzo
Thiamine before glucose
multivitamine, folic acid
Hydratation
Monitor vitals, decrease stimulation
CIWA –Ar scale
 Treatment of dependance
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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)
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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 2:1
 Delusions and hallucinations may occur in 50% of
those who use
Cocaine/amphetamine
 Usually « binge » use
 At a small dose:
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Increase in BP, tachycardia, tachypnea, mydriasis
 At a larger dose:
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Arrythmia, seizures, stroke, resp depression, death
 CRASH: craving, depression - anhedonia, hypersomnia,
+ appetite
 Medical problems: STDs, pulmonary dz…
 Psychosis: delusion, hallucinations, stereotypies
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Antipsychotic: haldol
 Rapid development 0f tolerance
 Sexual dysfonction
 Traitement: supportive, vaccine?
Opioids
 Intoxication
 Myosis
And (1)
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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 mostly
 Male to female ratio is 3 :1
 Most 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 use
 Very 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:
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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
• Withdrawal
Not in the DSM
- Insomnia
- Loss of appetite
- Irritability
- Diaphoresis tremor
Cannabis
 5% lifetime use
 Highest among 18-21 y.o.
 Euphoric effects appear within minutes, peak at 30 mins
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and last 2-4 hours
Motor and cognitive effects can last 5 to 12 hours
Possible sensitization
Mood d/o – self medication?
Amotivationnal syndrome
Increase risk of other drugs abuse
Possible indication for glaucoma, cancer/HIV – nabilone
Hallucinogens
 Psilocybin (mushrooms), mescaline, MDMA
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(ecstasy), LSD
Act as sympathomimetics
Cause hypertension, tachycardia, hyperthermia and
dilated pupils
Tolerance develops rapidly and remits within several
days of abstinence
Physical dependence and withdrawal do not occur
Often contaminated with anticholinergic drugs
Panic reactions (bad trips)
Duration variable (shrooms 4-6 hrs, LSD 6-12 hrs)
Phencyclidine (PCP)
 “angel dust”
 A dissociative anaesthetic and hallucinogen
 Commonly causes paranoia and violence
 May remain detectable in urine up to a week
 Associated with 3% substance abuse deaths
PCP
 Effects are dose dependent
 At low doses acts as a CNS depressant, with
nystagmus, blurry vision, incoordination
 At moderate doses hypertension, dysarthria, ataxia,
muscle rigidity
 At 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 seizures
 Longer term risk of brain injury, liver damage, bone
marrow depression, peripheral neuropathies,
immunosuppression
Urine toxicology
 Alcohol: 7-10 hrs
 Benzodiazepine : 3 days
 Cocaine : 6-8 hrs (metabolites 2-3days)
 Marijuana: 3 hrs to 4 weeks
 Codeine: 48 hrs
 Heroin: 36-72 hrs
MCQs
Neuropsychological effects of hallucinogens
may include all of the following EXCEPT:
a) miosis
b) tremor
c) hyper-reflexia
d) incoordination
e) blurred vision
Cocaine withdrawal can include all of the
following EXCEPT:
a) Crash sleep
b) anergia
c) anhedonia
d) euphoria
e) continued craving
Alcohol withdrawal includes all of the
following EXCEPT:
a) autonomic hyperactivity
b) tremor
c) starts within 2-4 hours after prolonged drinking
d) nausea
e) 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 reaction
b) delirium tremens
c) mania
d) schizophreniform reaction
e) post-operative delerium
Which of the following is best treated with high dose
benzodiazepines:
a) schizophrenia, catatonic type
b) major depression
c) generalized anxiety disorder
d) delirium tremens
e) psychogenic amnesia
A thorough assessment for the presence/absence of
alcohol withdrawal should include questions about all
of the following EXCEPT:
a) nausea and vomiting
b) mood
c) difficulty walking (ataxic gait)
d) visual disturbances
e) tremulousness
Sources
 Toronto Notes and MCC Practice Exams 2003
 MCC Self-Administered Evaluating Examination -
Online