Transcript Addictions
Addiction Psychiatry Martina Smit, MD Theresa Lo Sept 18, 2015 Objectives • Overview of addiction: • neurobiology • DSM5 criteria for substance use disorders • specific substance syndromes • Assessment • Substance use history • Treatment options, resources Addiction: A primary, chronic disease of • Brain reward • Motivation • Memory, and related circuitry American Society of Addiction Medicine REWARD CIRCUITRY Associative learning High significance to substance, Substance-rel’d cues Marks salience of reward Signals rewarding event Will occur http://neurowiki2012.wikispaces.com/file/view/Reward_circuit.jpg/315908202/Reward_circuit.jpg Neurotransmitters and Effects Dynorphin: dysphoria Dopamine: dysphoria CRF: stress Serotonin: dysphoria Norepinephrine: stress GABA: anxiety, panic attacks Glutamate: hyperexcitability Opioid peptide: dysphoria Koob GF, Simon EJ. The Neurobiology of Addiction: Where We Have Been and Where We Are Going. Journal of drug issues. 2009;39(1):115132. General diagnostic criteria SUBSTANCE-RELATED AND ADDICTIVE DISORDERS DSM5 Substance Use disorder 2 or more in 12 months: • Larger amts/longer period than intended • Persistent desire/unsuccessful efforts to cut down • A great deal of time spent to obtain, use, recover • Craving • Recurrent use fail to fulfill major role obligations • Continued use despite problems due to substance • Important activities given up or reduced • Recurrent use in physically hazardous situations • Continue use despite knowledge of phys or psychol problems • Tolerance • withdrawal Severity • Mild: 2-3 symptoms • Moderate: 4-5 symptoms • Severe: 6+ symptoms Physiologic dependence Tolerance • need more for same effect; • or, less effect with same amount Withdrawal • characteristic syndrome; • Or, take same or similar substance to avoid it SPECIFIC SUBSTANCE SYNDROMES Alcohol intoxication • Slurred speech • Dizziness • Incoordination • Unsteady gait • Nystagmus • Impairment in attention or memory • Stupor or coma - Many receptors involved Alcohol: low risk use • Men <65yo • No more than 3 drinks/day AND • No more than 15 drinks/week • Women <65yo • No more than 2 drinks/day AND • No more than 10 drinks/week • Special occasions: • No more than 4 drinks at a time for men • No more than 3 drinks at a time for women Alcohol withdrawal: (2 or more) • • • • • • • • • Autonomic hyperactivity Increased hand tremor Insomnia Nausea or vomiting Transient hallucinations (visual, tactile, auditory) Psychomotor agitation Anxiety Grand mal seizures Delirium tremens Alcohol withdrawal mgmt • Inpt vs outpt • Benzos • Fixed-dose vs symptom-triggered (CIWA) • Thiamine IM, multivitamins • Investigations? • CBC, Lytes incl K, Mg, LFTs, INR, BAL Cannabis intoxication 1. Behavioral or psychological changes • Lower doses: • Relaxation, euphoria, altered time/sensory perception; • Higher doses: • Hypervigilance/paranoia; anxiety/panic; derealization/depersonalization; hallucinations 2. 2 or more of: Conjunctival injection, increased appetite, dry mouth, tachycardia ***chronic THC use in youth associated with psychosis/schizophrenia -acts on cannabinoid receptors (found throughout CNS) Cannabis withdrawal • 3 or more: • • • • • • • Irritability, anger or aggression Nervousness or anxiety Sleep difficulty (insomnia, disturbing dreams) Decreased appetite or wt loss Restlessness Depressed mood At least 1 phys sx: abdo pain, tremors, sweats, fever, chills, HA Stimulant intoxication 2 or more • • • • • • • • Tachycardia or bradycardia Pupillary dilation Elevated or lowered BP Perspiration or chills Nausea or vomiting Wt loss Psychomotor agitation or retardation Muscle weakness, respiratory depression, chest pain, arrhythmias • Confusion, seizures, dyskinesias, dystonias, or coma Mechanism: cocaine: Monoamine reuptake inhib; Amphet: MAO inhib, DA+NE release Stimulant Withdrawal “Crashing” • Dysphoria • 2 or more of • • • • • Fatigue Vivid, unpleasant dreams Insomnia or hypersomnia Increased appetite Psychomotor retardation or agitation Opioid intoxication • Pupillary constriction (or dilation due to anoxia in severe OD) AND • Drowsiness or coma • Slurred speech • Impairment in attention or memory ***OD life-threatening respiratory depression Burgeois J et al Eds 2012 Opioid withdrawal Early to Moderate • • • • • • • Anorexia Anxiety Craving Dysphoria Fatigue Headache Irritability acrimatio n Mydriasis (mild) Perspiration Piloerection “cold turkey” Restlessness Rhinorrhea Yawning Moderate to Advanced • • • • • • • Abdo cramps Broken sleep Hot/cold flashes Incr BP Low-grade fever Muscle/bone pain Muscle spasm “kick the habit” • Mydriasis • Nausea, vomiting Sedative-Hypnotics • Barbiturates • Lethal in OD • Benzos • Bind to bzd receptors, enhance GABA • Z-drugs (zopiclone) • Intoxication and withdrawal similar to alcohol Hallucinogens (LSD, others) • LSD interferes with serotonin neurotransporters • Psilocybin, mescaline, [mdma] • Intoxication (2 or more): • • • • Pupillary dilation Tachycardia Sweating palpitations blurred vision tremors incoordination PCP, ketamine • Antagonize NMDA glutamate receptors • Intoxication (2 or more): • • • • • • • • VERTICAL or horizontal nystagmus HTN or tachycardia Numbness, diminished responsiveness to pain Ataxia Dysarthria Muscle rigidity Seizures or coma hyperacusis Inhalant intoxication (2 +) • Dizziness • Nystagmus • Incoordination • Slurred speech • Unsteady gait • Lethargy • Depressed reflexes • Psychomotor slowing • Tremor • Generalised muscle weakness • Blurred vision or diplopia • Stupor or coma • euphoria A 43yo F is brought to ER after becoming aggressive with a police officer during a routine traffic stop. She is noted to be extremely argumentative, with a labile mood. She makes several sexually inappropriate remarks to the examining physician. Examination reveals an unsteady gait, slurred speech, nystagmus and flushed face. The patient is afebrile, HR 78, respiratory rate 24/min. This pt’s presentation is most consistent with acute intoxication from which of the following? A. Alcohol B. Cannabis C. Cocaine D. Hallucinogens E. Opioids Focus 2011 A 32yo M is brought to the ER after sustaining a generalised tonicclonic seizure. Pt it noted to be hypervigilant and extremely abusive and aggressive. He suspects that the technicians may be taking blood samples from him for illegal purposes. He complains of nausea. Past medical hx is unremarkable and the pt is currently taking no meds. Examination reveals pt to be diaphoretic. He is afebrile, pulse 124, respirations 28 and BP 164/96. Pupils are dilated, but reactive to light. The pt’s presentation is best explained by acute intoxication from which of the following? A. Alcohol B. Cannabis C. Cocaine D. Heroin E. Phencyclidine Focus 2011 ASSESSMENT Screening • All pts presenting for substance use treatment should be screened for co-occuring MH disorders • All pts presenting for MH treatment should be screened for co-occurring substance use disorders CAGE Questionnaire • • • • Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? • Scoring: Item responses on the CAGE are scored 0 or 1, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. Copyright: © American Psychiatric Association Substance Use HX: TRAPPED • Treatment History (detoxification, treatment programs, medications, 12-step programs) • Route of administration (smoked, orally ingested, snorted, inhaled/"huffed," injected IV/IM/SC) • Amount (money spent, "pills," "bags," "vials," grams, ounces per bottle, frequency) • Pattern of use (binge, daily, solitary, period of heaviest use, etc.) • Prior abstinence (duration, what has helped in past, both in and out of a controlled environment) • Effects (direct and indirect, adverse, physical, social, legal, positive, withdrawal,etc.) • Duration of use (age of first use, most recent use) Welsh CJ. Academic Psychiatry 2003:27:289 Stages of change Prochaska & DiClemente 1992 Physical Exam http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/p sychiatry-psychology/drug-abuse-and-addiction/Default.htm Meds TREATMENT Alcohol • • • • Naltrexone Acamprosate Disulfiram Possibly (some evidence): topiramate, baclofen Opioids • Methadone • Buprenorphine • Symtomatic trx (e.g. Clonidine, ibuprofen, tylenol, lorazepam, phenergan, imodium) Nicotine • NRT (gum, patch, inhaler, spray) • Bupropion • Varenicline • 42yo F is started on a medication for alcohol dependence. At a party, she decides to have one drink. Shortly thereafter, she becomes nauseated, tachycardic, and hypertensive with marked facial flushing. The medication was most likely: • A. Acamprosate • B. Naltrexone • C. Disulfiram • D. Naloxone Psychosocial TREATMENT Psychosocial • • • • • • • CBT Motivational enhancement 12-step Interpersonal therapy Family/group/marital Self-help Case management Treatment settings • • • • Outpatient Day programs Residential Recovery houses… • A patient with alcohol dependence is referred for substance treatment by his family practitioner. The patient is not sure his drinking is that problematic. Which of the following would be the best initial approach? • A. motivational interviewing • B. CBT • C. Psychodynamic psychotherapy • D. Supportive psychotherapy • E. 12-step program Focus 2011 • A 45yo Caucasian single M mechanical engineer has a two-year history of depression and 20 years of problematic alcohol consumption. He has found 12-step programs partially helpful for his drinking, but is now motivated to receive a professional, integrated approach to managing both his depression and drinking. He has researched treatment options and would like to try a course of CBT and medication. Which one of the following is the best medication approach to address his depressive sx and addictive behavior? • Lorazepam only • Naltrexone and sertraline • Naltrexone only • Sertraline and lorazepam • Sertraline only Focus 2011