B2B – Substance use

1. B2B – Substance use Dr Tin Ngo-Minh, R4 Psychiatry April 2010

2. 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.

3. 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

4. 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?

5. 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%

6. 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

7. Alcohol Peak blood concentrations in 30-90 mins Rapid 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 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

8. 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% resolutionafter 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

9. Alcohol/benzodiazepine/barbiturate • Intoxication (1) • Slurred speech • Incoordination • Unsteady gait • Nystagmus • Impaired attention or memory • Stupor or coma • Withdrawal (2) • Autonomichyperactivity • Tremor • Insomnia • N/V • Hallucinations • Psychomotor agitation • Anxiety • Grand mal seizures

10. Alcohol Withdrawal • 5% have SSx 6-48hrs afterstopping ETOH • Reguliar use, symptoms of withdrawalbetween 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 • Potentiallyletal: DT in 1% • Atrisk: abnLFTs, oldage, medical complications, hx of DT, tolerance

11. ETOH/Benzo/sedatives • Acute treatment of withdrawal: • Benzodiazepine – reach a level of sedation, thengradualtapering • Valium j1- 10-20mg TID, j2: 10-20mg BID; j3 10-20mg DIE ; or otherBenzo • Thiamine 100mg • Thiamine before glucose • multivitamine, folicacid • Hydratation • Monitor vitals, decrease stimulation • CIWA –Ar scale • Treatment of dependance • 12 steps, AA • Antabuse (disulfiram), naltrexone? • Treatment of the underlying MDE?

12. 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… • Recommendedtemporary use of benzos

13. 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

14. Cocaine/amphetamine • Intoxication (2) • Tach or bradycardia • Mydriasis • Elevated or lowered BP • Chills or perspiration • N/V • Weightloss • Psychomotoragiation or retardation • Muscle weakness, respdepression, CP, arrythmia • Confusion, seizure, dyskinesias, dystonias or coma • Withdrawal(2) CRASH • Fatigue • Vivid and unpleasantdreams • Insomnia orhypersomnia • Increasedappetite • Psychomotor agitation or retardation

15. 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

16. Cocaine/amphetamine • Usually « binge » use • At a small dose: • Increase in BP, tachycardia, tachypnea, mydriasis • At a larger dose: • Arrythmia, seizures, stroke, respdepression, death • CRASH: craving, depression - anhedonia, hypersomnia, + appetite • Medicalproblems: STDs, pulmonary dz… • Psychosis: delusion, hallucinations, stereotypies • Antipsychotic: haldol • Rapiddevelopment 0f tolerance • Sexual dysfonction • Traitement: supportive, vaccine?

17. Opioids • Intoxication • Myosis And (1) • Drowsiness or coma • Slurred speech • Impairment of attention or memory • Withdrawal(3) • Dysphoricmood • N/V • Muscle aches • Lacrimation or Rhinorrhea • Mydriasis, piloerection or sweating • Diarrhea • Yawning • Fever • insomnia

18. 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 Semisyntheticopioids: heroin

19. Opioids • Half life of heroinis a few minutes vs methadone: 20hrs • Heroin: withdrawalssxafter ½ day, max after 2-3days • Methadone: withdrawalafter 36hrs max after 5days • Tolerance and withdrawal syndrome after 3 weeks of use • Veryunpleasantwithdrawal: chronology: • « craving » • PhysicalSSx: 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: • Respiratorydepression (+ isassociatedwithothersedatives) • Rx: naloxone 0.1-0.5mg q3-5min

20. Cannabis • Intoxication (2) • Conjonctival injection • Increasedappetite • Dry mouth • tachycardia • Withdrawal • Not in the DSM • Insomnia • Loss of appetite • Irritability • Diaphoresis - tremor

21. Cannabis 5% lifetime use Highest among 18-21 y.o. Euphoric effects appear within minutes, peak at 30 mins and last 2-4 hours Motor and cognitive effects can last 5 to 12 hours Possible sensitization Mood d/o – self medication? Amotivationnal syndrome Increaserisk of otherdrugs abuse Possible indication for glaucoma, cancer/HIV – nabilone

22. Hallucinogens Psilocybin (mushrooms), mescaline, MDMA (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)

23. 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

24. 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

25. 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

26. 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

27. 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

28. MCQs

29. Neuropsychological effects of hallucinogens may include all of the following EXCEPT: a) miosis b) tremor c) hyper-reflexia d) incoordination e) blurred vision

30. Cocaine withdrawal can include all of the following EXCEPT: a) Crash sleep b) anergia c) anhedonia d) euphoria e) continued craving

31. 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

32. 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

33. 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

34. 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

40. Sources • Toronto Notes and MCC Practice Exams 2003 • MCC Self-Administered Evaluating Examination - Online