Psychiatry - Angelfire



Psychiatry Peter Nguyen

Tuesday March 7, 2001 Michelle Umengan

Substance Abuse and Addictive Disorders Part II: Medical Aspects

Dr. Parikh spent much of his time reading the PPT slides word for word, that is, when he had slides to use (see below). I have included everything he said during the lecture (including some of his more candid quotes). He emphasized several points that we need to know for the USMLE (yes, he emphasized many many points). I am hoping that these are the same points that we need to know for our upcoming test.

DEFINITIONS

➢ Intoxications: maladaptive behavior associated with recent drug ingestion or overdosing. The effects vary widely among persons and depend upon the dose. .

➢ Withdrawal: Syndrome of symptoms following cessation of a drug. This implies tolerance and indicates dependence.

➢ Tolerance: Decreased effect with the same amount of a drug. A person will thus need to increase the dosage to get the same effects. Very common among all the substances we will talk about today.

➢ Abuse: a maladaptive pattern with continuous usage resulting in legal, social or occupational problems.

➢ Dependence: psychological (continuous craving for the substance) and/or physical (characterized by tolerance) need to continue taking the substance. There will be withdrawal if dependence truly exists.

➢ Addiction: Term is not used anymore and thus has been deleted from medical nosology. Nonspecific term implying psychological dependence and drug seeking behavior

ALCOHOL – EPIDEMIOLOGY

➢ In US, it is the most common substance-related disorder. About 85-90% of all US residents have had an alcoholic drink at least once in their lives.

➢ According to the DSM-IV, alcohol is the most frequently used brain depressant. This will be asked on our USMLE and Dr. Parikh really wants us to remember this.

➢ After heart disease and cancer, alcohol is the third largest health problem in the US today.

➢ 111 million people use alcohol each month with 32 million people engaging in binge drinking (5 or more drinks on one occasion in at least one month) and 11 million people engaging in heavy drinking (5 or more drinks on 5 or more occasions in one month). 10 million people are under the age of 21.

ALCOHOL RELATED DISORDER – PREVELANCE

➢ Higher prevalence in men:

▪ 20% of men v. 10% of women meet criteria for alcohol abuse.

▪ 10% of men v. 3-5% of women meet the criteria for alcohol dependence.

▪ Men > women in binge and heavy drinkers

➢ Reported 200,000 deaths each year

➢ Common causes of death in relation to alcohol (listed in order from greatest to least prevalant): suicide, cancer, heart disease (MI), and liver disease (cirrhosis).

➢ Is responsible for 50% of all homicides and 25% of all suicides.

➢ Reduces life expectancy by about ten years.

➢ Comorbid mental disorders: antisocial personality d/o, mood d/o, anxiety and suicide.

ALCOHOL DEPENDENCE – NATURAL HISTORY

➢ Dr. Parikh quickly read this slide and added nothing.

ALCOHOL – ETIOLOGY

➢ Childhood history – a person is at high risk with an ADHD and conduct d/o or if there is a family history of alcoholism.

➢ Psychodynamic – alcohol use is to hide emotional pain or some type of anxiety. Alcohol gives them a sense of power or a euphoric feeling.

➢ Social Settings – frequent and excessive drinking is a socially accepted behavior in college dorms and military bases.

➢ Behavioral Factors – alcohol causes an intense euphoria, helping to calm people down and deal with emotional pain. This encourages people to drink for most of their lives.

➢ Genetic-familial – this is the most important. If one parent is an alcoholic, the increased risk is 4x. If both parents are, the risk is 8x. Alcoholism is very common among monozygotic twins compared to dizygotic. Even if a child (whose biologic parents are alcoholics) is adopted, s/he still has a 4x risk.

STATE MARKERS

➢ This is another very common USMLE question. We will be asked what labs are commonly found in alcoholic patients.

➢ GGT > 30 – GGT means alcoholism. “I want you to know this for your USMLE.”

➢ MCV (mean corpuscular volume) ( 91 – RBCs get bigger in alcoholism

➢ Elevated TG, cholesterol and uric acids

➢ Elevated liver enzymes (SGOT/SGPT)

➢ Low serum folate level due to the malabsorption from the small intestine. “This is the other question you will see on the USMLE”

ALCOHOL – ABSORPTION AND METABOLISM

➢ Single drink = 12 grams of alcohol which is the content of:

▪ 12 oz beer = 3.6% ethanol

▪ 4 oz wine = 40% ethanol

▪ 1-1.5 oz of liquor (whiskey or gin) = 40% ethanol

➢ One of the above drinks will increase the alcohol blood level of a person to 15-20mg/dl, which can be metabolized in one hour.

➢ 10% is absorbed in the stomach and the remainder is absorbed in the small intestine. Peak level occurs at 30-90 minutes.

➢ Food delays absorption

➢ Absorption is rapid with beverages containing 15-30% alcohol

➢ Alcohol is uniformly dissolved in the body’s water. Thus, tissues containing a high amount of water receive a high concentration of alcohol.

➢ The liver metabolizes 90% of alcohol, with the kidney and lung metabolizing the remaining 10%. The body metabolizes about 15mg/dl/hr.

aldehyde

ADH dehydrogenase

Alcohol ((( acetaldehyde ((((( acetic acid

ADH = alcohol dehydrogenase

➢ Aldehyde dehydrogenase is inhibited by disulfiram (antabuse). It is the most commonly used drug in psychiatry for rehabilitation and detoxification. By inhibiting aldehyde dehydrogenase, disulfiram creates a buildup of aldehyde in the body. Aldehyde is a toxic compound that makes the person very sick, thus decreasing the person’s desire to drink. “This too is very important.”

➢ Asian people and women have a lower ADH content and thus get intoxicated more easily.

EFFECTS ON THE HUMAN BODY

➢ Central Nervous System

▪ Enhances the GABA receptor. “Remember this. This may be on the USMLE too.”

▪ Inhibits the reticular activating system (RAS) causing drowsiness and sedation and leading to difficulty making decisions.

▪ Inhibits spinal tracts resulting in ataxia, slurred speech, and nystagmus

▪ Causes cerebral atrophy.

▪ “This is very important! This is a test question! Remember this! Highlight! Make three four lines! This is very important!!!!!!! It will come all the time – medicine, surgery, whatever.”

◆ Wernicke’s Encephalopathy – acute neurologic disorder with the following triad:

◦ Confusion

◦ Ataxia

◦ Occulomotor abnormalities.

This is due to thiamine deficiency in the mamillary bodies. Treatment is to give daily thiamine (IV or oral). Within 15 days or so everything gets better. Thus, it is reversible. Any patient coming into the ER with alcohol intoxication should receive a banana bag: IV glucose, Mg++, and thiamine

◆ Korsakoff’s Psychosis: chronic condition (thiamine deficiency not treated) characterized by another triad:

◦ Confabulation (patients have a hard time remembering things so they make up stories)

◦ Profound retrograde (hard time recalling information already learned) and/or antegrade (hard time learning new things) amnesia

◦ Peripheral neuropathy.

This is due to long-term untreated thiamine deficiency. Thiamine is administered for 3-12 months and often the psychosis is irreversible.

▪ Sleep cycle - causes an increase in ease in falling asleep (decreased sleep latency), decreased stage 4 sleep and increased sleep fragmentation with frequent awakenings

▪ Dr. Parikh said that we don’t need to remember the next point in the PPT slides beginning with “alcohol induced inhibition of …”

▪ Chronic alcohol users have a lot of nutrition deficiencies, making them polyneuropathic (tingling, numbness, absent ankle jerks, distal muscle weakness and wrist drop).

➢ Liver

▪ In the beginning, alcohol causes:

◆ Hepatomegaly because of the fatty tissue infiltration (fatty liver)

◆ Hepatitis

◆ Cirrhosis and even liver cancer (hepatoma).

▪ Inhibits uric acid secretion, which might cause gout.

▪ Increases serum lactate causing metabolic acidosis.

▪ If someone is too drunk, respiratory depression can occur.

➢ GI Tract

▪ Esophagus and stomach

◆ Esophagitis

◆ Esophageal varices – rupture of these varices leads to death

◆ Gastritis

◆ Achlorhydria

◆ Gastric ulcers

▪ Pancreas

◆ Pancreatitis – USMLE question: the two causes of pancreatitis are alcohol use and tobacco use.

◆ Pancreatic insufficiency

◆ Pancreatic cancer.

▪ Interferes with the ability to absorb folate (most important vitamin).

➢ Cerebrovascular and cardiovascular

▪ 1-2 drinks a day helps to increase HDL. However, drinking too much will decrease HDL and increase LDL.

➢ Blood Producing Symptoms

▪ Alcohol is one of the causes of thrombocytopenia (important to know).

▪ Increases MCV (as stated above).

➢ Fetal Alcohol Syndrome – PROBABLY AN EXAM QUESTION

▪ 35% risk of having a child with birth defects:

◆ Craniofacial, limb and/or heart defects: mental retardation, small head, diminished physical size, facial abnormalities (flat bridge of the nose and epicanthal eye fold).

ALCOHOL INTOXICATION

➢ Mild – euphoria (this is why people drink)

➢ Severe – slurred speech, uncoordination, unsteady gait, nystagmus (need to remember this because this is what we look at when someone comes into the ER), impairment of memory, tachycardia, hypothermia, slow respiration, dilated pupils, and coma. These are the classic signs that we need to know.

➢ Treatment:

▪ IV hydration because they lose a lot of fluid

▪ Multivitamin because most alcoholics are malnourished (thiamine, folate and multivitamin – we must remember these three things.)

▪ Benzodiazepines (lorazepam and diazepam) for detoxification. Alcohol withdrawal is very life-threatening (seizures and respiratory arrest)

▪ If the patient is unconscious, transfer them to CICU: make sure they are warm, maintain their airway

▪ Mannitol or steroids are used if the patient has increased intracranial pressure

ALCOHOL WITHDRAWAL

➢ “This is the cream of butter of the USMLE. They will ask you so many questions about alcohol withdrawal, so you know … listen to me.”

➢ Autonomic hyperactivity – if you don’t remember anything else you need to know this. This is a core feature of alcohol withdrawal. The patient will have tachycardia (>100), HTN, sweating, anxiety, palpitations, flushing, hand tremor, insomnia, vomiting, visual hallucinations (see zigzag lines, colors or halos in their eyes), agitation and grand mal seizure (this is a USMLE question).

➢ So remember two things: grand mal seizure and autonomic hyperactivity.

➢ Onset – tremors begin within 6-8 hours after cessation, psychotic symptoms and perceptual disturbances 8-12 hours, seizure 12-24 hours.

➢ Withdrawal seizures (Rum Fits) – tonic-clonic seizures. Risk factors: head injuries, CNS infections and neoplasms, hypoglycemia, hypomagnesemia and hyponatremia. In chronic alcoholics we always check the Mg++ levels. This is why Mg++ is part of the banana bag (see above).

➢ Alcohol withdrawal delerium/Delerium Tremens (DT) – again, this is USMLE time. Confusion, disorientation, autonomic hyperactivity and visual hallucinations are core features. Occurs on the 2nd or 3rd day of withdrawal. Patients with DT are extremely violent. DT is a life-threatening condition.

➢ Treatment – same tx as intoxication: IV hydration, thiamine, glucose, multivitamin, high calorie diet and detox with benzodiazepines (patients are weened off benzos over a five day period – this is done to avoid grand mal seizures).

➢ Patients are so violent that if they are restrained they can go into hyperthermia leading to muscle damage (rhabdomyolysis) and renal failure. Also, do not give antipsychotics because these reduce the seizure threshold and increases seizures

REHABILITATION (ALCOHOL)

➢ Drugs:

▪ Disulfiram – patient must be good health, motivated and cooperative. MOA discussed above.

▪ Naltrexone – decreases craving

▪ SSRIs (Prozac and Zoloft) or trazodone – to control craving

➢ Alcoholics Anonymous (AA) – this will be the answer on the USMLE for support groups for rehabilitation

➢ Halfway House – for counseling and helping people get a job

PRINCIPLES OF TREATMENT OF SUBSTANCE USE DISORDERS

➢ Detoxification – 1st thing to do

➢ Insistence on abstinence from all substances

➢ Involvement of families

➢ Toxicology screen-periodic screens to test compliance

➢ Self-help groups – AA/NA (narcotics anonymous) groups

➢ Sanctioned treatment – loss of driver’s license or professional license if they drink alcohol

➢ Contingency contracting – reward positive behavior

From this point on Dr. Parikh lectured on without the accompaniment of PPT slides. To his dismay (and ours) he forgot to save his slides after 4 hours of work spent towards creating them. He said that all of the information given from this point on is very relevant and that he will not give any extraneous information.

“In discussing each drug, I will give you three things: features of intoxication, features of withdrawal, and chronic effects of use”

SPEED – AMPHETAMINE, ICE, CRYSTAL

➢ The receptor to remember is the dopamine receptor

➢ There are three main drugs under this group:

▪ Amphetamines

▪ Metamphetamines

▪ Stimulants (e.g.Ritalin/methylphenidate or Dexedrin)

➢ 18-15 yo is the age group with the highest risk of abuse

➢ People can develop tolerance as well as physical and psychological dependencies. As a result of these dependencies, you can expect to see withdrawal symptoms in patients coming off of these drugs.

➢ Clinical features of intoxication:

▪ HTN

▪ Tachycardia

▪ Sweating, chills

▪ Psychomotor agitation

▪ Nausea/vomiting

▪ Confusion

▪ Seizures – may be a USMLE question.

➢ Clinical features of withdrawal

▪ Vivid nightmares – (this is very important) due to disturbances in REM cycling,

▪ Depression or dysphoria

▪ Weight gain (when actually on amphetamines, people lose weight) due to increased appetite. “I think the word for increased appetite is munchies. M-U-N-C-H-I-E-S”

▪ Hypersomnia

▪ Psychotic – patients look like paranoid schizophrenics. (Another test question)

▪ Haldol is the treatment for withdrawal.

▪ Bruxism – teeth grinding (this was on Dr. Parikh’s USMLE)

➢ Chronic Effects of Use

▪ HTN

▪ MI

▪ If using IV, then the patient can have: HBV, HIV, skin infections, and infective endocarditis

ECSTASY – MDMA

➢ “MDMA is a long name so don’t try to remember it. Just remember ecstasy.”

➢ Key feature is that it gives a sense of closeness and comfort

SEDATOHYPNOTIC

➢ “Sedato means sedation and hypnotic means hypnosis”

➢ Drugs:

▪ Benzodiazepines – Valium/diazepam, Ativan/lorazepam – used as a sedative or an anxiolytic

▪ Barbiturates – Phenobarbital, pentobarbital

➢ Intoxication is the same as alcohol intoxication – Dr. Parikh referred back to the alcohol intoxication slide. Respiratory depression is the most important.

➢ Withdrawal is the same as alcohol withdrawal – Dr. Parikh referred back to the alcohol withdrawal slide. Main thing to remember is grand mal seizure. So know that grand mal seizures can occur as a result of withdrawal from the following drugs: alcohol, Benzodiazepines, barbiturates and chlorohydrate (a hypnotic).

MARIJUANA –HEMP, HASHIS, GANJA, CANNIBIS, BHANG

➢ Cannibinoid receptor is located in the basal ganglia and the hippocampus.

➢ Patients will develop tolerance as well as psychological dependency but physical dependency is very rare.

➢ Intoxication

▪ “Red eye” – dilatation of conjunctival vessels

▪ m-u-n-c-h-i-e-s

▪ Dry mouth

▪ Tachycardia

▪ Impaired motor skills – patients will have lots of accidents. If asked on a test (Block II or the USMLE?) what drug causes impaired motor skills, pick alcohol. If alcohol is not a choice, pick ganja.

▪ Photosensitive – heightened perception of color

▪ Amotivational syndrome – seen after doing hemp for 3 or 4 years. “You need to remember this. This will come on the test.”

▪ Flashbacks – vivid imagination of their hallucinations

➢ Used medically in cancer and glaucoma. Bhang has also been used to increase appetite in AIDS or HIV patients.

COCAINE – SNOW, COKE, CRACK, THE LADY, THE GIRL

➢ Crack is a very potent form of cocaine

➢ Constricts blood vessels – potent vasoconstrictor

➢ Used as a local anesthetic – eye condition, toes surgery or ear operation

➢ Dopamine receptor

➢ Powerful tolerance as well as physiological and psychological dependence

➢ Intoxication is the same as speed. The most important one is seizure. “Highlight this. They might ask you about cocaine intoxication and seizure.”

➢ Formication – tactile hallucinations where the patient has a sensation of bugs crawling on their skin

➢ Physical effects – same effects as amphetamines

▪ HTN

▪ MI

▪ Subaortic hemorrhage

▪ Nasal septum rupture – leads to problems breathing

▪ If using IV: HBV and HIV

▪ Infective endocarditis

➢ Withdrawal is the same as amphetamine withdrawal

▪ Typical name given to withdrawal from the lady is “blue” (sad or depressed) or crashed

▪ Typical depression with vivid nightmares – once again, as seen with amphetamines

➢ Treatment:

▪ Dopamine agonists: stimulates DA receptors so it reduces the trailing: amantadine and bromocriptine

▪ Tricyclic antidepressants (TCAs) – Imipramine or desipramine

VISUAL HALLUCINOGENS

➢ Patients will have:

▪ Visual hallucinations – perceptual abnormalities where the patient sees geometric designs and halos

▪ Derealization – the world is changing and the patient doesn’t feel that they are real.

➢ When patients have a lot of perceptual problems or visual hallucinations, it is called flashback.

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