Substance Use Disorders Pt.1, Ch 14

Substance Use Disorder Criteria

• Requires two or more symptoms from a list of eleven
• Symptoms include increased use, hazardous use, interpersonal problems, neglected responsibilities, abandoned interests, time spent using, cravings, failed attempts to quit, mental and physical health problems, tolerance, and withdrawal

Important Terms Related to Substance Use Disorders

• Intoxication: Reversible syndrome caused by excessive substance use, impacting CNS and physical/psychological functioning.
• Overdose: Occurs when substance use exceeds the body's ability to metabolize it, leading to life-threatening complications.
• Withdrawal: Symptoms that occur upon abrupt reduction or discontinuation of a substance, causing physical and psychological disruptions.
• Blackouts: Periods of amnesia that occur during or following alcohol consumption.
• Tolerance: Decreased effect with repeated use, requiring larger doses for the same effect.
• Cross tolerance: Tolerance to one substance, leading to tolerance for similar substances.
• Synergistic effects: Combined effect of two or more substances, resulting in a greater effect than when used individually.
• Cross-dependence: Dependence on one substance, reducing withdrawal symptoms with another substance.
• Antagonistic effects: When two substances counteract each other, reducing the effect of one or both substances.
• Flashbacks: Re-experiencing sensory or emotional components of intoxication after substance use has stopped.
• Co-occurring disease/dual diagnosis: Having both a substance use disorder and another mental health disorder.
• Codependency: A dysfunctional relationship pattern where one person enables another's substance use.

Substance Use Disorder Characteristics

• Impacts ability to fulfill role obligations.
• Attempts to cut down or control use fail.
• Intense cravings for the substance.
• Excessive time spent obtaining or recovering from substance use.
• Difficulty in interpersonal relationships or social isolation.
• Engaging in hazardous activities while impaired.
• Tolerance development and increased dosage needed for desired effect.
• Substance-specific withdrawal symptoms after discontinuation.

States of Substance Use

• Substance intoxication: Reversible syndrome characterized by CNS disruption, impaired judgment, and social/occupational dysfunction.
• Substance withdrawal: Symptoms are specific to the substance and cause physical and psychological disruptions.

Classes of Psychoactive Substances

• Alcohol
• Caffeine
• Inhalants
• Cannabis
• Opioids
• Stimulants
• Tobacco
• Sedatives/hypnotics/anxiolytics

Predisposing Factors of Substance Use Disorder

• Biological factors:
  • Genetics: Hereditary component, particularly in alcoholism.
  • Biochemical: Alcohol may produce morphine-like substances in the brain, potentially contributing to addiction.
• Psychological factors:
  • Developmental influences
    • Punitive superego: Individuals with punitive superegos may turn to drugs to reduce anxiety and enhance feelings of power and self-worth.
    • Fixation in the oral stage of psychosexual development
  • Personality factors: Certain personality traits may increase susceptibility to addictive behaviors.
  • Cognitive factors: Irrational thinking patterns are often linked to substance use and addiction.
• Sociocultural factors:
  • Social learning: Children and adolescents may be more likely to use substances when their parents model substance use.
  • Peer group influences: Substance use may be promoted within peer groups.
  • Conditioning: Pleasurable effects of substance use provide positive reinforcement, encouraging continued use.
  • Cultural and ethnic influences: Some cultures have higher rates of substance abuse compared to others.

Assessment Guidelines for Substance Use Disorder

• Specific drugs used: Type and frequency of use.
• Route of administration: How the substance is consumed.
• Signs and symptoms of intoxication, overdose, and withdrawal: Physical and mental changes experienced.
• Vital signs: Heart rate, blood pressure, respiration, etc.
• Physical and mental health assessments and history: Past and present health conditions.
• Screening tools: Standardized tests to assess substance use and dependence.
• Psychosocial history: Coping mechanisms, job, support system, etc.
• Insight and interest in additional treatment: Individual's understanding and willingness to engage in treatment.

CNS Depressants and Opioids

• Include alcohol, benzodiazepines, barbiturates, and opioids.
• Intoxication symptoms: Disinhibition, drowsiness, impaired judgment, slurred speech, unsteady gait, and decreased vital signs.
• Overdose symptoms: Cardiovascular and respiratory depression, shock, convulsions, coma, and death.
• Withdrawal symptoms: Elevated vital signs, tremors, nausea, muscle aches, sweating, anxiety, insomnia, disorientation, hallucinations, delirium, and seizures (except for opioids).

Alcohol Use Disorder

• Patterns of use:
  • Phase I (Pre-alcoholic phase): Alcohol is used to relieve everyday stress and tension.
  • Phase II (Early alcoholic phase): Blackouts occur, indicating a reliance on alcohol.
  • Phase III (Crucial phase): Loss of control and physiological dependence become apparent.
  • Phase IV (Chronic phase): Emotional and physical disintegration, with frequent intoxication.
• Effects on the body:
  • Wernicke's encephalopathy: Severe thiamine deficiency in alcoholic patients.
  • Korsakoff's psychosis: Confusion, memory loss, and confabulation in alcoholic patients.
  • Peripheral neuropathy: Nerve damage in the extremities.
  • Alcoholic myopathy: Muscle weakness and atrophy.
  • Leukopenia and thrombocytopenia: Reduced white blood cell count and platelet count respectively.
  • Sexual dysfunction: Erectile dysfunction, decreased libido, and menstrual irregularities.
  • Esophagitis, gastritis, and pancreatitis: Inflammation of the esophagus, stomach, and pancreas.
  • Alcoholic cardiomyopathy: Heart muscle damage and weakness.
  • Alcoholic hepatitis: Liver inflammation.
  • Cirrhosis of the liver: Scarring of the liver, leading to portal hypertension, ascites, esophageal varices, and hepatic encephalopathy.
• Fetal Alcohol Syndrome (FAS): A set of birth defects caused by maternal alcohol consumption during pregnancy. Children with FAS may experience learning difficulties, speech and language delays, behavioral problems, and physical abnormalities.

Alcohol Intoxication and Withdrawal

• Alcohol intoxication: Occurs at blood alcohol levels between 100 and 200 milligrams per deciliter, characterized by impaired coordination, slurred speech, and altered behavior.
• Alcohol withdrawal: Typically starts within 4 to 12 hours of cessation or reduction of alcohol use. It can range from mild symptoms (anxiety, tremors, and sweating) to severe symptoms (delirium tremens).

Withdrawal Delirium

• A medical emergency that can be life-threatening.
• Peaks around 48 to 72 hours after last or reduced alcohol intake.
• Includes severe autonomic hyperactivity, changes in level of consciousness, delusions, hallucinations, and severe mood changes.

Treatment for Alcohol Withdrawal and Withdrawal Delirium

• Prevent harm related to mental health manifestations: Ensure safety and manage symptoms effectively.
• Medication management:
  • Benzodiazepines or barbiturates: Used for gradual tapering to manage withdrawal symptoms.
  • Clonidine: Reduces autonomic hyperactivity.
  • Beta blockers: Help manage heart rate and blood pressure.
  • Anticonvulsants: Prevent seizures.
  • B-vitamin replacement: Thiamine (B1), folic acid, and cyanocobalamin (B12) are crucial to address vitamin deficiencies.
• CIWA-Ar: Assessment tool used to measure the severity of alcohol withdrawal.

Medications to Maintain Sobriety from Alcohol

• Disulfiram (Antabuse): Makes alcohol consumption unpleasant by inducing nausea, vomiting, and flushing.
• Naltrexone: Reduces cravings and blocks the euphoric effects of alcohol: Available as a daily pill (Revia) and a monthly extended-release injection (Vivitrol).
• Acamprosate: Reduces alcohol cravings and helps maintain abstinence.

Opioids

• Most commonly misused: Heroin, oxycodone, hydrocodone, morphine, fentanyl, and codeine.
• Overdose: Requires immediate medical attention and can be reversed with naloxone (Narcan) or nalmefene (Revex). Supportive care is also crucial.
• Withdrawal: Begins hours after last use and can be unpleasant, but is usually not life-threatening.
• Withdrawal treatment:
  • COWS Score: Assessment tool to measure opioid withdrawal severity.
  • Substitution and eventual taper: Gradually switching to a less potent opioid (e.g., methadone) and then tapering down.
  • Medication-assisted treatment (MAT): Includes use of medications like methadone, buprenorphine, or naltrexone.
  • Methadone: Long-acting opioid agonist that reduces cravings and prevents withdrawal.
  • Buprenorphine or buprenorphine/naloxone (Suboxone): Partial opioid agonist that helps manage withdrawal and cravings.
  • Naltrexone: Opioid antagonist that blocks the effects of opioids.
  • Clonidine: Can help manage withdrawal symptoms like anxiety and muscle aches.

CNS Stimulants

• Include amphetamines/methamphetamines, synthetic stimulants, non-amphetamine stimulants, cocaine/crack, caffeine, and nicotine.

Cocaine and Crack

• Intoxication symptoms: Elevated heart rate, blood pressure, and body temperature; dilated pupils; euphoria and alertness; agitation and anxiety; paranoia and hallucinations; insomnia; and psychosis.
• Overdose symptoms: Respiratory distress or arrest, stroke, heart attack, seizures, coma, and death.
• Withdrawal symptoms: Severe fatigue, intense craving, depression, suicidal thoughts, and increased appetite.

Amphetamines and Methamphetamines

• Intoxication symptoms: Similar to cocaine, but effects can last longer.
• Overdose symptoms: Similar to cocaine overdose, but may also include hyperthermia, muscle breakdown, and kidney failure.
• Withdrawal symptoms: Similar to cocaine withdrawal.

Caffeine

• Intoxication symptoms: restlessness, insomnia, anxiety, and tremors.
• Withdrawal symptoms: Headache, fatigue, irritability, and muscle aches.

Nicotine

• Withdrawal symptoms: Dysphoria (unease or dissatisfaction), anxiety, irritability, difficulty concentrating, increased appetite, cravings.

Inhalants

• Commonly abused inhalants include spray paint, glue, lighter fluid, aerosols, and paint thinners.
• Intoxication symptoms: Drunkenness, slurred speech, dizziness, euphoria, lack of inhibitions, vision changes, and psychomotor retardation.
• Overdose effects and treatment: Severe damage to liver, brain, and heart; respiratory arrest; fatal dysrhythmias; sudden sniffing death; coma and death.
  • Treatment focuses on supporting affected organ systems. Vitamin B12 and folate may be used to address neurological symptoms.
• Withdrawal symptoms: Mood changes, panic attacks, restlessness, body aches, tremors, nausea, runny nose, watery eyes, and seizures.