PHA 535: Substance Use Disorder (SUD)

• The presentation discusses substance use disorder (SUD), a topic in Human Behavior & Psychiatry (PHA 535), taught by Professor Levy in Spring 2025.
• There are 998 slides in the presentation.

DSM 5 TR Substance Classes

• The DSM 5 TR outlines substance classes including: Alcohol, Caffeine, Hallucinogens, Inhalants, and Opioids.
• Sedatives/hypnotics, anxiolytics, stimulants, cannabis, and other/unknown "designer drugs" are also included in the DSM 5 TR substance classes.

DSM 5 Substance Use Disorder (SUD) Definition

• SUD is defined by cognitive, behavioral, and physiological symptoms.
• SUD involves difficulty stopping substance use despite significant substance-related problems.
• The term SUD replaces "abuse" and "addiction" terms, although *DSM 5 TR has 88 addiction references.

"Addiction" Definition

• Addiction involves interaction with a person, activity, or substance on a regular basis, which alters mood and has life damaging consequences.
• The addicted person has difficulty stopping.

Need for Treatment

• In 2021, 94% of people aged 12 or older with a substance use disorder did not receive any treatment.
• Nearly all people with a substance use disorder who did not get treatment at a specialty facility did not think they needed treatment.

SUD Statistics

• Substance Use Disorder (SUD) affected 48.7 million (17.3%) people aged 12 or older in the past year.
• Drug Use Disorder (DUD) affected 27.2 million (9.7%) in the past year, about 1 in 10 people.
• Opioid Use Disorder (OUD) affected 6.1 million (2.2%) in the past year; a little over 1 in 5 with a past year DUD had an OUD (about 2% overall).
• Alcohol Use Disorder (AUD) affected 29.5 million (10.5%) people, about 1 in 10 people in the past year.
• 1 in 12 adults (8.4%) aged 18 or older had both AMI (Any Mental Illness) and an SUD in the past year; over one third of adults aged 18 or older who had AMI also had an SUD in the past year.

Misuse of CNS Stimulants

• Misuse of CNS Stimulants affects 10.2 million people.
• Among people aged 12 or older, 3.6% misused CNS stimulants, including 1.9% who used cocaine, 1.5% who misused prescription stimulants, and 1.0% who used methamphetamine.
• Cocaine, prescription stimulants and methamphetamine are the CNS stimulants that constitute misuse.
• 1 in 30 people aged 12 or older misused CNS stimulants.
• Significant drug diversion is caused by the illegal distribution or abuse of prescription drugs, or their use for purposes not intended by the prescriber.

Opioid, Hallucinogen, and Prescription Tranquilizer Misuse

• NSDUH asked respondents aged 12 or older about their use of these drugs in the 12 months before the interview.
• 8.9 million people are affected by opioid misuse.
• 8.5 million people are affected by hallucinogen use.
• 4.8 million people are affected by prescription tranquilizer or sedative misuse.
• 2.3 million people are affected by inhalant use.
• 991,000 people are affected by fentanyl misuse.
• Adolescent Inhalant Use is at 554,000 (2.2%) among adolescents aged 12 to 17, about 2% used inhalants in the past year.

DSM 5 TR SUDs Terms

• Intoxication: Mood altered.
• Tolerance: Needing more substance for the same effect, influenced by genetic variability, brain changes, changes in receptors and increased metabolism.
• Withdrawal: Physiologic and/or psychological symptoms after discontinuing a substance.
• Substance/medication induced mental disorders.

Hallucinogen Persisting Perception Disorder (Flashbacks)

• Recurrences of the drug's intoxicating effects hours, days, or years after use.
• Caused by any recreational drug that alters mental processes and interferes with sensory perceptions.
• It can be emotional, somatic, and perceptual.

Hallucinogen Persisting Perception Disorder - Examples

• Trails of images of moving objects may occur.
• Music may be experienced.
• Halos or trailing after-effects of images may be seen.
• Objects appearing larger/smaller than they are.
• An image of an object despite it not being there anymore.
• Visual snow or air that looks grainy/textured may be noticed.
• Hallucinations, especially of geometric patterns may be experienced.
• False perceptions of movement in peripheral vision.
• Inanimate objects appear alive (walls appear to be "breathing" or growing).
• Flashes/intensity of color may be enhanced.

Drugs Commonly Associated with Flashbacks

• Lysergic acid diethyl amide (LSD).
• Psilocybin (found in hallucinogenic mushrooms).
• Mescaline (found in peyote hallucinogenic cactus).
• Cannabis (marijuana).
• 3,4-methylene dioxymethamphetamine (MDMA).
• Diphenhydramine (Benadryl).
• Dextromethorphan (DM in cough syrup).

DSM 5 TR SUD Diagnosis - Patterns of Use

• Diagnosis requires ≥2 (of 10) criteria in the last 12 months.

Impaired Control

• Increasing amount and time used.
• Unsuccessful desire to cut down/stop.
• Time spent finding, using, recovering.
• Craving and triggers.

Social Impairment

• Failure to fulfill obligations: school, work, home.
• Continue using despite consequences.
• Discontinue social, occupational, or recreational behaviors.

Risky Use

• Using in dangerous situations.

Pharmacological Criteria

• Tolerance: higher amount of substance needed for same effects.
• Withdrawal symptoms.

"SUD Predisposition"

• Includes conditioned responses, substituting short-term pleasure for long-term, poor coping skills, shame and guilt, and "family of origins" issues.
• Biologic predisposition: Lower dopamine 2 receptors/endorphins.
• Thrill-seeking behavior (ADHD?).
• Brain changes that evoke cravings.
• Poor decision making - frontal lobe physiology, especially younger than years of age 25, before frontal lobe fully developed.
• Impulsivity: frontal lobe.
• "Anyone-can become addicted".

Withdrawal Symptoms

• Severe symptoms: alcohol, opioids, sedatives, hypnotics, and anxiolytics.
• Less severe symptoms: stimulants and cannabis.
• Little to no withdrawal: hallucinogens and inhalants.
• Withdrawal symptoms generally opposite of intoxication/use symptoms.

SUD Specifiers

• Early remission: No drug use for > 3 months, but < 12 months (except craving).
• Sustained remission: No drug for > 12 months (except craving).
• Controlled environment: Access to substance restricted (jail).
• "Recovery": In the process of abstaining from drugs.

Substance-Induced Disorders

• Include psychosis, bipolar disorder, depression, anxiety, sleep disorder, delirium, neurocognitive symptoms, and sexual dysfunction.
• It is important to ensure the condition is not caused by a drug.

Non-Substance Related Disorder(s) in DSM 5 TR

• Gambling is included.
• Sex, shopping, exercise, relationships, food, sugar, and social media are not included due to "insufficient peer-reviewed evidence to diagnose as a mental disorder”.

Substance Use Remission/Relapse

• Like any other chronic medical illness.
• Frequency, intensity, and duration of treatment predicts outcome.
• 70% will eventually able to abstain or decrease use and not meet SUD criteria

Drug Scheduling Guide (United States)

• Drugs are categorized into schedules (I-V) based on their potential for abuse and dependence, and whether they have medicinal qualities.

Illicit "Street" Drugs

• "Laced" or "cut" with other substances.
• Doses, quality, and purity cannot be assured.
• Can be dangerous and deadly.

March 11, 2022

• Army Football Player and West Point Cadets are among Victims of Wilton Manors Fentanyl Overdose.
• All six of the patients were men in their early 20s and were in town for spring break.
• Thought they were using pure cocaine.
• 2 became unconscious after giving CPR to two of the victims.

Active/Lethal Dose Ratio and Dependence Potential

• A chart plots psychoactive drugs based on dependence potential versus active dose/lethal dose.

Britain, drug harm score (out of 100), selected drugs, 2010

• Harm to users and others is taken into consideration.

Cannabinoids/Cannabis

• Most commonly used illicit drug in America.
• Classified as a depressant, stimulant, or hallucinogen.
• Active ingredient: Tetra hydro cannabinol (THC).
• MOA: Cannabinoids (CB1, CB2) receptors.
• AKA: marijuana, Hashish, THC, "pot", "weed".
• Use: swallowed (eaten), smoked, dermatologic.
• THC levels reach peak in 10-30 min, lipid soluble.
• Long half-life of 50 hours.
• Cannabidiol (CBD) is still a schedule substance.

Cannabinoids Effects: PEERS

• PEERS is an acronym for:
  • Psychosis paranoia "bad trip".
  • Eating ↑ (munchies) and ↑ thirst
  • Euphoria/ relaxation
  • Red eyes (conjunctivitis)
  • Slow reaction time/ "stoner" persona
• Anti-emetic (central).
• Lower intraocular pressure.
• Ataxia.
• Impaired judgement.

Cannabinoids Long-term Effects

• Impaired memory/ learning ("stoners”).
• Cough.
• Frequent respiratory infections.
• Depression.

Cannabinoid Hyperemesis Syndrome

• Usually, cannabinoid use for over a year.
• Cyclical vomiting and sever abdominal pain ("scromiting”).

Cannabinoid Hyperemesis Syndrome Treatment

• IV Fluids.
• Haloperidol or droperidol IV.
• Antiemetics: odansetron (Zofran).
• Capsaicin cream to abdomen.
• D/C cannabinoids.

Cannabinoid Withdrawal

• 3 or more symptoms, including: irritability, anger, aggression, anxiety, sleep difficulty, decreased appetite/weight loss, restlessness, depressed mood, and/or physical symptoms such as abdominal pain, shakiness/tremors, sweating, fever, chills, or headache.

Cannabinoids Treatment

• Detox and rehabilitation.
• reSET: the first Prescription Digital Therapeutic (PDT) approved by the FDA to treat SUDs; implemented with Cognitive Behavioral Therapy (CBT), with a contingency management system (reward/consequences); the app is called Pear reSET.
• Motivational Enhancement Therapy (MET): like Motivational Interviewing with pre-assessments.
• Treat other psychiatric symptoms.

Stimulants MOA

• Increases norepinephrine, dopamine levels, and serotonin (to a lesser extent).
• Caffeine also blocks adenosine receptors to keep user alert and awake.

Stimulants

• Cocaine, amphetamine, methamphetamine, (Crystal Meth), methylphenidate (Ritalin), MDMA (also a hallucinogen), caffeine, nicotine.
• Consumed: injected, smoked, snorted, swallowed, rectal.
• Short-term effects: ↑↑pulse, BP, and metabolism, feelings of exhilaration, energy, wakefulness.
• Long-term possibilities: rapid or irregular pulse, reduced appetite, weight loss, nervousness, insomnia.

Cocaine

• Very addictive.
• Route: nasal, IV, or smoked.
• "Crack cocaine".

Cocaine Associated Illnesses

• Long term ↑↑↑CVA and MI risk.
• Nasal septum perforation (vasoconstriction).
• Cocaine Induced Cardiomyopathy.
• Paranoia.
• Drug-Induced Depression.
• Renal Tubular Necrosis.
• Rhabdomyolysis.

Amphetamines

• Lasts longer than cocaine, with dose-dependent intensity.
• Route: oral, IV, nasally, smoked.
• Appetite suppressant.
• Productivity enhancer.
• Chronic use yields similar nasal perforation if snorted as with cocaine.
• Possible permanent psychosis.
• No known substances to reduce cravings.
• Treatment similar to cocaine.

Methamphetamine (Crystal Meth)

• Similar to amphetamines, except lipophilic and higher potency.
• Additional methyl group.
• Various ways to deliver.

Methamphetamine (Crystal Meth) SUD

• Skin problems, acne appears or worsens, obsessive skin picking often causes sores, bugs crawling beneath the skin (hallucinations).
• Facial musculature & fat: Meth suppresses appetite, leads to long periods of undernourishment, consumes muscle tissue & facial fat, giving gaunt, hollowed-out appearance.
• Teeth and gums: Caused by several factors, tooth enamel dissolved; tooth decay risk increased; saliva production diminishes; cravings for sugary foods increased; oral hygiene generally neglected. Heavy tooth-grinding is additional effect.

Methamphetamine Signs and Symptoms

• M – meth mouth (poor dentition)
• E – excoriations (skin picking)
• T – tactile (bugs crawling under skin)
• H – hallucinations (visual, auditory)
• A – agitation/anxiety (arousal)
• M – mood disturbances
• P – pupillary dilation (bruxism)
• H – hyperthermia/hypertension
• E – euphoria
• T – tachycardia
• A – anorexia
• M – medicowesome 2017
• I – irritability
• N – for sympathetic stimulation
• E stimulation

Synthetic Cathiones: "Spice" "Bath Salts"

• Is a combination of mephedrone and methylone function like MDMA, ↑↑ dopamine.
• Methylene dioxy pyro valerone (MDPV) acts like cocaine and blocks the reuptake of dopamine and norepinephrine.
• 10 x more potent than cocaine.
• Similar symptoms to other stimulants and violent behavior.
• Psychosis.

Stimulants: Medical Concerns

• Cardiac work-up: BP, ECG, troponins, CPK.
• Rhabdomyolysis: CPK, U/A.
• Treat with sedatives acutely with such medications as Benzodiazepines and Antipsychotics like haloperidol.

Stimulants Withdrawal

• Not severe, but cravings can be.
• Exhaustion with sleep (crash).
• Depression.
• Increased appetite.
• Pupillary constriction.

DSM 5 TR Caffeine Use Disorder

• Recent consumption of caffeine >250 mg (2.5, 8oz cups with 95mg).
• Five or more of these symptoms: Restlessness, nervousness, excitement, insomnia, flushed face, diuresis, GI (diarrhea/constipation/gastritis), muscle twitching, tachycardia/ cardiac arrhythmia, periods of inexhaustibility, and/ or psychomotor agitation (like akathisia).

Caffeine Withdrawal Symptoms

• Caffeine Withdrawal include: lack of concentration, depression, constipation, headache, flu-like symptoms, muscle pain/stiffness, irritability, sleepiness.

Treatment Stimulant Use Disorder

• Same as marijuana.
• 12 step programs.
• In-patient treatment.
• Treat any underlying condition: Sleep disorder (insomnia, hypersomnia), depression, and/or ADHD.
• Caffeine: decrease gradually to prevent withdrawal headaches.
• "Matrix model".

Matrix Model: "Hard Core"

• Strong therapeutic relationship between client and counselor.
• Teach clients: time structure and healthy lifestyles.
• Educate about withdrawal effects and cravings, like craving curve.
• Relapse prevention, coping techniques, and relapse analysis.
• Involve family/significant others to gain their support for—and prevent their sabotaging of—treatment.

Depressants

• Barbiturates: phenobarbital, thiopental; gamma hydroxybutyrate (GHB); flunitrazepam (Rohypnol) aka "Ruffies"; and methaqualone (Quaalude).
• MOA: Increases gamma-aminobutyric acid (GABA), causing sleepiness and relaxation.
• High risk of overdose/death, especially with alcohol, hence Schedule I.
• No reversal agent.

Depressants - Benzodiazepines

• Benzodiazepines: diazepam (Valium), chlordiazpoxide (Librium).
• MOA: Increases gamma-aminobutyric acid (GABA), causing sleepiness and relaxation, Non-Selective.
• More safer than barbiturates.
• Reversal agent: Flumazenil, a GABA receptor antagonist.
• Hypnotics (sleeping pills): selective GABA alpha 1 receptor effects and less tolerance and dependence than benzodiazepines.

Depressants - Short and Long-term effects

• Swallowed, injected.
• Short-term effects: ↑ feeling of well-being: mellow.
• ↓ Inhibitions, anxiety, pulse and breathing, BP concentration.
• Long-term possibilities: fatigue, confusion, impaired coordination/memory/judgment, respiratory depression, arrest, and death.

DSM 5 TR Withdrawal From Depressants, Two or More Symptoms

• Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
• Hand tremor.
• Insomnia.
• Nausea or vomiting.
• Visual, tactile, or auditory hallucinations.
• Psychomotor agitation.
• Anxiety.
• Seizure risk (up to 3 weeks).
• PAWs, or post-acute withdrawal syndrome difficulty with any stress, emotional liability for weeks and months.

Benzodiazepine/Hypnotics/Barbiturate Withdrawal

• Decrease benzodiazepine dose every 1-2 weeks and not more than 5 mg Diazepam dose equivalent.
• Consider carbamazepine or valproic acid if rapid taper is required.
• In-patient treatment for barbiturates withdrawal due to risk of seizures.

Hallucinogens and Dissociatives

• There are different hallucinogens.

Hallucinogens MOA

• 5-HT2A receptor agonists (opposite MOA of aripiprazole).
• ↑ Serotonin, dopamine, norepinephrine.
• Short-term effects: Euphoria and "oneness", altered perception.
• ↑ temperature, pulse, BP.
• ↓ appetite.
• Mydriasis (pupil dilation).
• Anxiety, sleeplessness, numbness, weakness, tremors, nausea.
• "Bad trips:" Paranoia, anxiety, severe terrifying thoughts, feelings of despair, fear of losing control/sanity/death.
• Long-term possibilities: Hallucinogen persisting perception disorder (flashbacks).

Hallucinogens- Naturally Occurring and Synthetic Agents

• Naturally occurring: peyote cactus (mescaline) and hallucinogenic mushrooms (psilocybin).
• Synthetic agents: LSD (lysergic acid diethylamide), MDMA (“Ecstasy“,“Molly“), DMT (dimethyltryptamine smoked, snuffed, iv), STP (2,5-dimethoxy-4-methylamphetamine, oral), salvia plant (mint-like plant from Mexico).

Hallucinogens Modes of Use

• A table shows LSD to have 7 different modes of use, peyote 5 different modes of use, psilocybin 6 different modes of use, DMT has 3 different modes of use, ketamine 5 different modes of use, PCP 6 different modes of use, and Salvia 4 different modes of use.

Dissociative Drugs

• “Not connected to body,“ like, general anesthesia.
• MOA: Antigonizes N-methyl-D-aspartate (NMDA) glutamate receptor (glutamate stimulates) except MDMA Increases serotonin and dopamine.
• Dissociative drugs included Ketamine, PCP (phencyclidine) MDMA, Dextromethorphan
• Consumed Injected, Swallowed, Smoked, Snorted
• Short term effects ↑ Pulse and BP Impaired motor function, Analgesia, Loss of sense of time
• Long term possibilities Memory loss, Numbness, Depression, Aggression Hallucinations
• N-methyl-D-aspartate receptor is a ligand of glutamate, which is the primary excitatory neurotransmitter in the human brain.

MDMA (XTC, Extacy, Molly)

• 3,4-methylene-dioxy-methamphetamine
• Designer “club drug"
• MOA: Affects serotonin (5HT) and predominantly 5HT2 receptor agonist
• ↑↑ Serotonin dopamine Norepinephrine, Glutamate
• ↑ Oxytocin, "hug drug”
• ↑↑ Empathy, personal insight, energy
• “Super antidepressant" Loss of sexual interest/pleasure
• 3-6 hour duration

MDMA Effects

• Euphoria.
• Bruxism.
• Altered sense of time.
• Heightened senses.
• Affectionate.
• "Oneness with the world".
• Impaired judgement.
• Persistent perception disorder.
• Rhabdomyolysis.
• Serotonin syndrome.
• Possible permanent hallucinogen persisting perception disorder (Flashbacks).

Seratonin Syndrome: H2ARM2

• H Hypertension.
• A Anxiety.
• R Restlesness.
• M Myoclonus.

Serotonin Syndrome Treatment

• Cyproheptadine
• Low stimulation environment
• BZD to treat agitation
• Treat hyperthermia with: Cold water NG lavage, Continuous application of cold water by sponging or using a spray bottle, placing a fan, Submerge a sheet in cold water, wring it out, and wrap the patient, apply ice packs: the groin, axillae, neck, and torso, cold saline infusion but monitor for shivering, Foley catheter to irrigate with cold saline
• Bath with water at 90 F (26.7 C) Colder temperature may cause shivering

MDMA Withdrawal

• Neuronal/brain damage
• Serotonin depletion associated with a variety of effects, including - Paranoid psychosis Panic anxiety depression, flashbacks, and cognitive changes

Phencyclidine (PCP) "Angel Dust" Characteristics

• Dissociative anesthetic.
• Similar to ketamine.
• MOA: NMDA receptor antagonist, increases serotonin, dopamine, and norepinephrine.
• Psychosis and analgesia.
• Intoxication causes severe dissociative reactions such as euphoria, paranoid delusions, hallucinations.
• Agitated/violent with decreased awareness of pain.
• Cerebellar symptoms - ataxia, dysarthria.
• Nystagmus vertical, horizontal, or torsional.
• No tolerance.

PCP Withdrawal

• Insomnia.
• Mood disturbance.

PCP Overdose Treatment

• Same as MDMA/serotonin syndrome.

Inhalants

• Helium, solvents, spray paint, whipped cream canister, glue.
• Inhaled (huffed).
• Causes brain damage from VOCs, anoxia.
• Short-term effects: stimulation, loss of inhibition, headache, N/V, slurred speech, loss of motor coordination, wheezing.
• Long-term possibilities: cramps, weight loss, muscle weakness, depression, memory impairment, CV and CNS damage, death.
• Amyl/butyl nitrite inhalants, “poppers": Used to enhance sexual excitement by smooth muscle relaxation and vasodilatation.

Alcohol (Ethanol)

• A depressant: GABA calms, increased by alcohol, and glutamate is stimulated but blocked by alcohol.
• Long term use causes upregulation (increase) of glutamate receptors.
• Increased tolerance.

CAGE Questionnaire

• Questionnaire to detect alcohol abuse including: Cut down, Annoyed, Guilt, Eye opener.
• Study determining that CAGE test scores ≥2 had a sensitivity of 93% and a specificity of 76% for the identification of problem drinkers.

Binge Drinking Alcohol (Ethanol)

• Responsible for more than 40% of the deaths and three-quarters of the costs due to excessive alcohol use.
• Defined as consuming 5 or more drinks on an occasion for men or 4 or more drinks on an occasion for women.
• Most people who binge drink are not dependent on alcohol.
• CDC estimates 1 in 6 binge drink.
• 25% of bingers doing so at least weekly, on average, and 25% consuming at least 8 drinks during a binge occasion.

Alcohol Intoxication

• Blood Alcohol Level: 0.08g/dl 30% of MVA deaths associated with blood alcohol levels >0.08 g/dL.
• Impairment begins at one drink.
• Progress from mood lability, disinhibition, impaired judgment, and poor coordination to neurologic impairment, dysarthria, amnesia, ataxia, obtundation.
• Observe for GAS (Gait, Alcohol, Speech).

Alcohol Danger

• Alcohol can be fatal (loss of airway protective reflexes, pulmonary aspiration, profound CNS depression).

Alcohol Health Effects

• Cirrhosis.
• Wernicke Korsakoff Syndrome (Thiamine Deficiency).
• Pancreatitis.
• Beri-Beri (Thiamine Deficiency).
• Dilated Cardiomyopathy.
• Peripheral Neuropathy.
• Testicular Atrophy.
• Cerebellar Degeneration.
• Permanent ataxia and uncoordinated movements.
• Gastritis.
• GI bleed.
• Cancer (especially throat).

Wernicke's Korsakoff Syndrome - Treatment

• Give Thiamine 100 mg IM.
• Check blood level after and OK to give glucose if needed, but give thiamine close after.
• IV 500 mg every 8 hours if deficient.
• Potential risk of increasing Wernicke encephalitis when giving glucose without thiamine.
• Remember COAT RACK - Confusion, Opthalmoplegia, Ataxia, Thiamine deficiency (Wernicke's) + Retrograde and Anterograde Amnesia, Confabulation, Korsakoff Syndrome.

Alcohol Abuse: Other Clinical Features

• Hypoalbuminemia.
• Anemia is also another significant clinical feature.

Alcohol Withdrawal

• GABA decreases along with Glutamate which causes DECREASED INHIBITION.
• Alcohol Withdrawal increase as the GABA becomes excited it is replaced with increased Glutamate.
• Agitatation HTN Tremor GI Upset Tachycardia.

CIWA Scoring - Clinical Institute Withdrawal Assessment for Alcohol Scale

• Clinical assessment tools are used, such as the CIWA Scoring and the shortened CIWA Scale, or SHOT scale.
• Treat if > 8 with benzodiazepines in detox.
• Highly subjective.
• Problem with articulation of symptoms.
• The score is useful in determining the severity of symptoms.
• The SHOT scale can indicate need for benzodiazepines.

When To Admit for Inpatient Detox

• CIWA score (12), elevated vitals, history of complicated withdrawal (DT's) medical issues (heart arrhythmia), unstable psychiatric issues (suicidal), failure of outpatient treatment pregnancy, High alcohol use.

Typical Timeline for Alcohol Withdrawal Syndrome (AWS)

• Minor Symptoms with 8 to 12 hrs.
• Alcohol Cessation includes: Anxiety, Insomnia, Gastrointestinal upset, Headache, Palpitations, Anorexia
• Alcoholic Hallucinosis, usually 12 to 24hr; orientation intact.
• Withdrawal Seizures with 24 to 48hours; may occur as early as 2 hours.
• Delirium Tremens can occur in hours or days (3 or >) with Agitation Hallucinations tachycardia Hypertension, fever, and Diaphoresis. Peak at 5 days to the last up to 7 days.

Delirium Tremens: Medical Emergency

• Acute, severe alcohol withdrawal syndrome.
• 3-7 days after the last drink (12 hours-8 days);Symptoms progress rapidly (Mental status changes as well).

Delirium Tremens

• Hallucinations: patient thinks he is in some other physical location and is interacting with that location.
• Physical exam shows: heavy sweating, fever, increased startle reflex, irregular heartbeat/tachycardia/HTN, rapid eye muscle movement, and rapid muscle tremors.

Treatment Alcohol Withdrawal

• Benzodiazepines (Valium): longer half-life and can start while drinking to prevent symptoms.
• The starting dose is 10 mg 3-4 times/day, avoid in liver failure.
• Doses as high as 2,000 mg if needed.
• lorazepam (Ativan): shorter half life, 2-4 mg 3-4x/day.
• Enough to suppress symptoms, then decrease 10-20% per day; if in doubt, treat, to prevent DTs.
• Can be given Rx and sent home with follow-up and instructions.
• Anticonvulsants reduce kindling from multiple withdrawals, help for protracted withdrawal, and use Carbamazepine or valproic acid.

Other DT Treatments

• Phenobarbital
• Propofol
• Dexmedetomidine
• Ketamine
• Intubation and ventilation in ICU

Counseling Steps for Patients who Abuse Alcohol or Drugs

• Motivational Interviewing
• Discuss physical problems (i.e., elevated LFTs, hepatomegaly, etc.)
• Make the office off-limits substance abuse, and present information negative health consequences.
• Involve family and other supports.
• Establish a working relationship with community treatment resources.
• The provider should provide follow-up; don't abandon unless abusive.

Available Alcohol Treatments

• Counseling.
• Detoxification: safely stopping alcohol use including out-patient/in-paitent programs.
• Long-term residential rehabs and half way houses,

ETOH Use Disorder- Relapse Prevention Medications

• Naltrexone (Vivitrol) 50mg po daily - First line, Can start while drinking, opioid antagonist blocks mu receptors, reducing euphoria and cravings, and hepatotoxicity at high doses so check LFT's.
• Acamprosate (Campral) 666mg po tid reduces cravings, Need to stop drinking first, stabilizes neuron excitation and inhibition may interact with GABA and Glutamate receptors Cleared renally (check kidney function).
• Disulfiram (Antabuse) blocks normal metabolism of alcohol from acetaldehyde to acetic acid, so it Causes a build up of acetaldehyde 5-10 times greater than normal, and Headache, violent vomiting occurs.
• Anti-convulsants: topiramate (Topamax) and gabapentin (Neurontin).

semaglutide (Ozempic)

• Drug treatment for Type II DM and weight loss.
• Further anecdotal reports of decreased alcohol cravings and desires are expected.

Drugs

• A table outlines many drugs and the mechanism at which they affect the brain.