Understanding Addiction

• Addiction is a complex condition, characterized by compulsive engagement in a specific behavior or substance use, despite harmful consequences.

Types of Addiction

• Substance-related addictions involve the compulsive use of drugs or alcohol, leading to significant impairment or distress.
• Behavioral addictions, also known as process addictions, involve compulsive engagement in behaviors such as gambling, gaming, sex, shopping, or internet use.
• Alcohol Use Disorder (AUD) is a chronic relapsing brain disease characterized by compulsive alcohol seeking and use, loss of control over alcohol intake, and negative emotional state when not using.
• Opioid addiction involves compulsive use of substances like heroin, morphine, and prescription painkillers, leading to physical dependence and withdrawal symptoms upon cessation.
• Stimulant addiction includes compulsive use of substances like cocaine, methamphetamine, and amphetamines, resulting in euphoria, increased energy, and potential cardiovascular complications.
• Gambling disorder involves persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress.
• Gaming disorder is characterized by persistent or recurrent gaming behavior, either online or offline, manifested by impaired control over gaming, increasing priority given to gaming, and continuation or escalation of gaming despite negative consequences.

Causes of Addiction

• Genetic factors play a significant role, with studies showing that individuals with a family history of addiction are more likely to develop addictive behaviors.
• Environmental factors, such as exposure to substance use during childhood, peer influence, and socioeconomic status, can contribute to the development of addiction.
• Psychological factors, including stress, trauma, anxiety, depression, and personality disorders, can increase the risk of addiction as individuals may turn to substances or behaviors as coping mechanisms.
• Neurobiological factors involve changes in brain structure and function, particularly in the reward pathways, making it difficult to resist cravings and impulses.
• The brain's reward system is activated by addictive substances or behaviors, releasing dopamine and creating a pleasurable sensation that reinforces the behavior.
• Repeated exposure to addictive substances or behaviors can lead to tolerance, requiring higher doses or more frequent engagement to achieve the same effect.
• Withdrawal symptoms occur when substance use is reduced or stopped, leading to physical and psychological discomfort and driving individuals to continue using to alleviate these symptoms.

Treatment Methods

• Detoxification is the first step, involving the safe removal of the substance from the body, often managed with medication to reduce withdrawal symptoms.
• Behavioral therapies, such as cognitive-behavioral therapy (CBT), help individuals identify and change negative thought patterns and behaviors associated with addiction.
• Motivational interviewing (MI) is a client-centered approach that enhances intrinsic motivation to change by exploring and resolving ambivalence.
• Group therapy provides a supportive environment where individuals can share experiences, learn coping strategies, and receive encouragement from peers.
• Medication-assisted treatment (MAT) involves the use of medications, such as methadone, buprenorphine, or naltrexone, to reduce cravings and withdrawal symptoms in opioid or alcohol addiction.
• Residential treatment programs offer intensive, structured care in a supportive environment, providing individual and group therapy, counseling, and relapse prevention strategies.
• Outpatient treatment programs allow individuals to receive treatment while living at home, attending therapy sessions and support groups on a regular basis.
• Dual diagnosis treatment addresses co-occurring mental health disorders, such as depression or anxiety, which can exacerbate addiction.

Preventive Measures

• Education programs in schools and communities can raise awareness about the risks of substance use and addictive behaviors.
• Early intervention programs target individuals at high risk of developing addiction, providing counseling and support to prevent escalation.
• Parental involvement is crucial, setting clear boundaries and monitoring children's activities to reduce exposure to substance use.
• Community-based programs can provide access to resources and support for individuals and families affected by addiction.
• Policy and legislation can restrict access to addictive substances and behaviors, such as alcohol, tobacco, and gambling.
• Promotion of healthy coping mechanisms, such as exercise, mindfulness, and social support, can reduce reliance on substances or behaviors to manage stress and emotions.
• Screening and assessment can identify individuals at risk of addiction, allowing for early intervention and treatment.

Impact on Mental Health

• Addiction often co-occurs with mental health disorders, such as depression, anxiety, bipolar disorder, and PTSD.
• Substance use can exacerbate symptoms of mental health disorders, making them more difficult to manage.
• Mental health disorders can increase the risk of addiction as individuals may use substances or behaviors to self-medicate.
• Addiction can lead to social isolation, relationship problems, and financial difficulties, contributing to feelings of depression and anxiety.
• Chronic substance use can alter brain function, affecting mood regulation, impulse control, and cognitive function.
• Dual diagnosis treatment is essential to address both addiction and mental health disorders simultaneously, improving outcomes and reducing relapse rates.
• Suicide risk is higher among individuals with addiction, particularly those with co-occurring mental health disorders.
• Integrated treatment approaches, combining therapy, medication, and support services, are most effective in addressing the complex interplay between addiction and mental health.

Alcohol Intoxication

• Symptoms include slurred speech, ataxia, emotional lability, and disinhibition.

Alcohol Withdrawal Timeline

• Symptoms appear in stages, with varying severity and timeframes.
• Mild symptoms (GI upset, tremors, agitation, insomnia) occur between 0-36 hours.
• Alcoholic hallucinosis (visual hallucinations with intact orientation) occurs between 12-48 hours.
• Withdrawal seizures occur between 6-48 hours.
• Delirium tremens (DTs), the severe stage, occurs at 48 hours and beyond.
• DTs involves delirium and cardiovascular compromise, and can be life-threatening.

Alcohol Withdrawal Pathophysiology

• Chronic alcohol consumption increases GABA (inhibitory) and decreases glutamate (excitatory).
• This leads to upregulation of glutamate receptors over time.
• Sudden alcohol cessation leads to a surge in glutamate and a drop in GABA.
• The result is net excitation and sympathetic overdrive.
• Sympathetic overdrive causes agitation, hypertension, tremor, GI upset, and tachycardia.
• Delirium further compounds cardiovascular risks in delirium tremens

Alcohol-Related Associations/Complications

• Cirrhosis can cause portal hypertension, bleeding, jaundice, asterixis, spider angiomata, palmar erythema; Labs may show abnormal LFTs, GGT, decreased platelets, or clotting factor changes.
• Wernicke-Korsakoff syndrome manifests with encephalopathy, ophthalmoplegia, ataxia, amnesia (anterograde or retrograde), and confabulation; consider thiamine levels or mammillary body imaging.
• Pancreatitis presents with epigastric pain radiating to the back, nausea, vomiting, chills, flank or periumbilical ecchymosis, elevated amylase and lipase, and potentially hypocalcemia.
• Beriberi: Dry beriberi = symmetrical peripheral neuropathy; Wet beriberi = high-output heart failure; check thiamine levels.
• Dilated cardiomyopathy presents with systolic heart failure symptoms (systolic murmur, S3 heart sound), dilated ventricles, ballooning of the heart, or bundle branch block on imaging.
• Cerebellar degeneration causes vertigo, ataxia, dysarthria, dysmetria, dysdiadochokinesia, abnormal finger-to-nose test, Stuart-Holmes sign (rebound elbows), or cerebellar drift.
• Gastritis: hematemesis, upper GI pain, indigestion, early satiety; look for endoscopy images or H. pylori test results (stool antigen or urease breath test).
• Marchiafava-Bignami disease can manifests with neuropsychiatric symptoms (personality change, dementia, psychosis); diagnosis is determined from imaging showing corpus callosum degeneration; associated with decreased B vitamin levels.

Opioid Intoxication

• Characterized by euphoria, CNS and respiratory depression, pinpoint pupils, and decreased gag reflex.

Opioid Withdrawal

• Symptoms include dilated pupils, lacrimation, sweating, nausea, vomiting, diarrhea, and yawning.

Opioid Associations

• Intravenous drug use is correlated with right-sided endocarditis and abscesses
• Endocarditis symptoms include Roth spots, Janeway lesions, splinter hemorrhages, Osler nodes, fever, shortness of breath. Labs/imaging may reveal valve vegetations, anemia, positive blood cultures;
• Abscesses: painful, warm, purulent, fluctuant masses; Labs may reveal leukocytosis and elevated inflammatory markers

Benzodiazepine Intoxication

• Causes ataxia, mild respiratory depression, and somnolence.

Benzodiazepine Withdrawal

• Causes insomnia, anxiety, and withdrawal seizures (which can occur 1-3 weeks after cessation).

Benzodiazepines vs. Barbiturates

• Both act on GABA to affect chloride channel opening.
• Benzodiazepines increase the frequency of chloride channel opening.
• Barbiturates increase the duration of chloride channel opening.

Cocaine Intoxication

• Causes pupil dilation, agitation, euphoria, tactile hallucinations (bugs crawling on skin), alertness, and arousal.

Cocaine Withdrawal

• Characterized by sleepiness, hunger, and depression.
• Cocaine increases dopamine, norepinephrine, and serotonin.

Cocaine Associations

• Nasal septum perforation due to vasoconstriction.
• Cocaine-induced cardiomyopathy.
• Paranoia, hallucinations.
• Drug-induced depression and suicidal ideation.
• Renal tubular necrosis and rhabdomyolysis.

Methamphetamine Intoxication

• Pupil dilation, agitation, euphoria, hallucinations, arousal, alertness, and wakefulness.

Methamphetamine Withdrawal

• Sleepiness, hunger, and depression.

Methamphetamine Associations

• Meth mouth: dental caries and poor dentition due to vasoconstriction, poor dental hygiene, and bruxism.
• Causes a strong burst of release of monoamine neurotransmitters.

PCP Intoxication

• Characterized by initial euphoria followed by violence and aggression, superhuman strength.
• PCP is an NMDA receptor antagonist, causing psychosis and analgesia.

PCP Withdrawal

• Mood disturbances and insomnia, but is NOT high yield.

PCP Associations

• Rotatory/torsional nystagmus.

MDMA (Ecstasy) Intoxication

• Hallucinations, euphoria, disinhibition, bruxism, altered sense of time and sensation.
• MDMA blocks the reuptake of serotonin and dopamine.

MDMA Withdrawal

• Anxiety, concentration difficulties, and depression, but NOT high yield

MDMA Associations

• Serotonin syndrome.
• Hyponatremia/thirst.
• Seizures.
• Bruxism
• Hallucinogen persisting perception disorder.

Marijuana Intoxication

• Calmness, reduced anxiety, altered judgment/reaction time, increased appetite, conjunctival injection (red eyes).

Marijuana Withdrawal

• Decreased appetite, insomnia, and irritability.

Marijuana Associations

• Psychosis and paranoia, particularly "bad trips."
• Cannabinoid hyperemesis syndrome: vomiting, nausea, relief with hot showers.