1. Dr Tin Ngo-Minh, R4 Psychiatry April 2010
B2B – Substance use
Dr Tin Ngo-Minh, R4
Psychiatry
April 2010

2. MCC Objectives Stimulant – Depressants - Volatile Inhalants toxidromes
Need for emergency care b/c of withdrawal SSx or other complications
LFTs and tests if suspected of ETOH abuse
CAGE
Alcohol withdrawal management, indications and contraindications for disulfiram, and naltrexone, methadone; outline management of withdrawal from opioids and benzodiazepines
Outline management for stopping nicotine including advice to quit, nicotine replacement therapy, setting quitting dates, behavioral counseling, information about community resources
Discuss guidelines for safe prescription writing for benzodiazepines and opioids.
Outline management of cardiovascular complications of cocaine and alcohol.
Outline prevention, detection, and management of infectious complications of IV drugs use including Hepatitis B, C, and HIV.

3. Definitions
Abuse: maladaptive use x at least > 1year causing at least 1:
failure to fulfill major role obligations (work, school, home etc);
Interpersonal problems
Legal problems
Physical health at risk while using (DWI, etc)
Dependence: maladaptive use at least > 1year causing at least 3:
Tolerance
Withdrawal
takes more than intended

4. Definitions Dependence (con’t)
Desire or unsuccessful attempt to cut down or control
+ time spent obtaining, using, recovering
Important social, occupational, recreational activities: given up or reduced
Continued use despite knowledge of physical or psychological problem
CAGE
Do you think you have a problem with ETOH use?

5. CAGE – Screening dependence
Have you ever tried to cut down in your drinking?
Have you ever been annoyed about criticism of your drinking?
Have you ever felt guilty about your drinking?
Have you ever had a morning eye opener?
Positive answer to >1 increases suspicion for ETOH dependance
Sensitivity 86%; Specificity 93%

6. Definitions
Intoxication: reversible syndrome causing behavioral or psychological changes due to a recent use
memory, orientation, mood, judgment and level of functioning
Withdrawal: syndrome due to cessation or reduction of a heavy or prolonged use causing significant problems in social, occupational or other areas of functioning
Tolerance: phenomenon in which, after repeated administration, a given dose of a substance produces a decreased effect
Cross tolerance: ability of one drug to be substituted for another each usually producing the same physiologic and psychological effects

7. Alcohol Peak blood concentrations in 30-90 mins
Rapid consumption and consumption on an empty stomach enhance absorption and decrease time to peak blood levels
Intoxication more pronounced as blood levels are rising
90% metabolized by hepatic oxidation
Body metabolizes approx one moderately sized drink per hour (ie one 12 oz beer, 4 oz wine, 1 oz liquor)
Cultural: Asians show increased acute toxic effects, Native Americans and Inuit have higher rates

8. ETOH Associated with: Epidemiology: 33% with ETOH abuse have MDE
ETOH abuse: 7-10% of general pop; 20-40% hospitalized patients
Involved in 30% of suicides; life time risk of suicide in alcoholics: 2-3.5% (50-120x more than general pop)
33% of alcoholics have at least 1 parent with alcoholism; 50% have at least 1 other family member with alcoholism
Child with 1 parent with ETOH dep: 25% risk of having the dz; 2 parents: 50%
33% with ETOH abuse have MDE
50% resolution after cessation of ETOH
Pattern: men: ETOH  MDE; women MDE  ETOH
Associated with:
Intox, withdrawal, Wernicke-Korsakoff syndrome, cerebral atrophy – dementia, cerebellar degeneration, polyneuropathy, myopathy, GI (75% of pancreatitis pt have ETOH dependence), hepatitis, cirrhosis, GI cancer, gastritis, esophagitis…; HTA, thrombocytopenia, anemia, + MVC, trauma, dehydration, seizures, decrease albumin, B12, folate, anxiety, depression, sexual dysfunction, sleep disorder, psychosis, etc

9. Alcohol/benzodiazepine/barbiturate
Intoxication (1)
Slurred speech
Incoordination
Unsteady gait
Nystagmus
Impaired attention or memory
Stupor or coma
Withdrawal (2)
Autonomic hyperactivity
Tremor
Insomnia
N/V
Hallucinations
Psychomotor agitation
Anxiety
Grand mal seizures

10. Alcohol Withdrawal
5% have SSx 6-48hrs after stopping ETOH
Reguliar use, symptoms of withdrawal between doses.
Chronology:
a) (8hrs) tremor, insomnia, nausea, tachycardia
b) (2days) diaphoresis, anxiety, agitation, + HTA, headache, hypervigilance
c) abn VS, DT, hallucinations, disorientation
Symptoms: delirium, marked autonomic hyperactivity (tachycardia, sweating, agitation, anxiety), vivid hallucinations, agitation tremor, fever, seizures
Potentially letal: DT in 1%
At risk: abn LFTs, old age, medical complications, hx of DT, tolerance

11. ETOH/Benzo/sedatives
Acute treatment of withdrawal:
Benzodiazepine – reach a level of sedation, then gradual tapering
Valium j mg TID, j2: 10-20mg BID; j mg DIE ; or other Benzo
Thiamine 100mg
Thiamine before glucose
multivitamine, folic acid
Hydratation
Monitor vitals, decrease stimulation
CIWA –Ar scale
Treatment of dependance
12 steps, AA
Antabuse (disulfiram), naltrexone?
Treatment of the underlying MDE?

12. Treatment of OD: flumazenil – caution… Other options for insomnia
Equivalence:
Lorazepam (ativan) 1mg
Clonazepam (Rivotril) 0.5mg
Diazepam (Valium) 10mg
Oxazepam (Serax) 20mg
Alprazolam (Xanax) 0.5mg
Treatment of OD: flumazenil – caution…
Other options for insomnia
Zopiclone? Benadryl? - Amytryptiline, buspirone, trazodone…
Recommended temporary use of benzos

13. Alcohol induced amnestic disorder
Wernickes encephalopathy: Reversible acute syndrome caused by thiamine deficiency (nystagmus, ataxia, confusion, 6th CN – lateral rectus). Treat with thiamine 100mg IM then PO
Korsakoffs syndrome: chronic condition result of thiamine deficiency, amnesia, confabulation, disorientation, polyneuritis, Rx with thiamine, 25% patients fully recover

14. Cocaine/amphetamine Withdrawal(2) CRASH Fatigue
Intoxication (2)
Tach or bradycardia
Mydriasis
Elevated or lowered BP
Chills or perspiration
N/V
Weight loss
Psychomotor agiation or retardation
Muscle weakness, resp depression, CP, arrythmia
Confusion, seizure, dyskinesias, dystonias or coma
Withdrawal(2) CRASH
Fatigue
Vivid and unpleasant dreams
Insomnia or hypersomnia
Increased appetite
Psychomotor agitation or retardation

15. Cocaine Most commonly used in 18 to 25 year old range
Male to female ratio of 2:1
Delusions and hallucinations may occur in 50% of those who use

16. Cocaine/amphetamine Usually « binge » use At a small dose:
Increase in BP, tachycardia, tachypnea, mydriasis
At a larger dose:
Arrythmia, seizures, stroke, resp depression, death
CRASH: craving, depression - anhedonia, hypersomnia, + appetite
Medical problems: STDs, pulmonary dz…
Psychosis: delusion, hallucinations, stereotypies
Antipsychotic: haldol
Rapid development 0f tolerance
Sexual dysfonction
Traitement: supportive, vaccine?

17. Opioids Intoxication And (1) Withdrawal (3) Dysphoric mood N/V
Myosis
And (1)
Drowsiness or coma
Slurred speech
Impairment of attention or memory
Withdrawal (3)
Dysphoric mood
N/V
Muscle aches
Lacrimation or Rhinorrhea
Mydriasis, piloerection or sweating
Diarrhea
Yawning
Fever
insomnia

18. Opioids Associated with abuse mostly Male to female ratio is 3 :1
Most users in their 30s and 40s
Natural derivatives of opium: codeine, morphine
Synthetic opioids: methadone, oxycodone, dilaudid, talwin, demerol
Semisynthetic opioids: heroin

19. Opioids Half life of heroin is a few minutes vs methadone: 20hrs
Heroin: withdrawal ssx after ½ day, max after 2-3days
Methadone: withdrawal after 36hrs max after 5days
Tolerance and withdrawal syndrome after 3 weeks of use
Very unpleasant withdrawal: chronology:
« craving »
Physical SSx: diaphoresis, rhinorrhea, lacrimation, yawning
Irritability, mydriasis, loss of appetite, piloerection
(after 1 day) diarrhea, N/V, fever, spams, insomnia, abd pain
Treatment of withdrawal: clonidine mg q4-6h; methadone?
Intoxication:
Respiratory depression (+ is associated with other sedatives)
Rx: naloxone mg q3-5min

20. Cannabis Withdrawal Not in the DSM Insomnia Loss of appetite
Intoxication (2)
Conjonctival injection
Increased appetite
Dry mouth
tachycardia
Withdrawal
Not in the DSM
Insomnia
Loss of appetite
Irritability
Diaphoresis - tremor
Autonomique: diaphorese, tachycardie

21. Cannabis 5% lifetime use Highest among 18-21 y.o.
Euphoric effects appear within minutes, peak at 30 mins and last 2-4 hours
Motor and cognitive effects can last 5 to 12 hours
Possible sensitization
Mood d/o – self medication?
Amotivationnal syndrome
Increase risk of other drugs abuse
Possible indication for glaucoma, cancer/HIV – nabilone

22. Hallucinogens Psilocybin (mushrooms), mescaline, MDMA (ecstasy), LSD
Act as sympathomimetics
Cause hypertension, tachycardia, hyperthermia and dilated pupils
Tolerance develops rapidly and remits within several days of abstinence
Physical dependence and withdrawal do not occur
Often contaminated with anticholinergic drugs
Panic reactions (bad trips)
Duration variable (shrooms 4-6 hrs, LSD 6-12 hrs)

23. Phencyclidine (PCP) “angel dust”
A dissociative anaesthetic and hallucinogen
Commonly causes paranoia and violence
May remain detectable in urine up to a week
Associated with 3% substance abuse deaths

24. PCP Effects are dose dependent
At low doses acts as a CNS depressant, with nystagmus, blurry vision, incoordination
At moderate doses hypertension, dysarthria, ataxia, muscle rigidity
At high doses agitation, fever, rhabdomyolysis, renal failure

25. Inhalants Volatile hydrocarbons inhaled for psychotropic effect
eg gasoline, kerosene, laquers, paint thinner, fingernail polish remover
Typically abused by adolescent males of low SEC groups

26. Inhalants: Intoxication
Mild euphoria, belligerence, assaultiveness, impaired judgment
Ataxia, confusion, slurred speech, decreased reflexes, nystagmus
Can go on to delirium and seizures
Longer term risk of brain injury, liver damage, bone marrow depression, peripheral neuropathies, immunosuppression

27. Urine toxicology Alcohol: 7-10 hrs Benzodiazepine : 3 days
Cocaine : 6-8 hrs (metabolites 2-3days)
Marijuana: 3 hrs to 4 weeks
Codeine: 48 hrs
Heroin: hrs

28. MCQs

29. Neuropsychological effects of hallucinogens
may include all of the following EXCEPT:
a) miosis
b) tremor
c) hyper-reflexia
d) incoordination
e) blurred vision

30. Cocaine withdrawal can include all of the following EXCEPT:
a) Crash sleep
b) anergia
c) anhedonia
d) euphoria
e) continued craving

31. Alcohol withdrawal includes all of the following EXCEPT:
a) autonomic hyperactivity
b) tremor
c) starts within 2-4 hours after prolonged drinking
d) nausea
e) irritability

32. A 30 year-old man presents in emergency with right lower quadrant abdominal pain. His wife reports that he had been drinking heavily in response to marital problems and had never had such pain before. Appendicitis was diagnosed and an appendectomy was successfully performed. Four days later the patient was anxious, restless, unable to sleep and claimed his wife was a stranger trying to harass him. The likeliest diagnosis is:
a) paranoid reaction
b) delirium tremens
c) mania
d) schizophreniform reaction
e) post-operative delerium

33. Which of the following is best treated with high dose benzodiazepines:
a) schizophrenia, catatonic type
b) major depression
c) generalized anxiety disorder
d) delirium tremens
e) psychogenic amnesia

34. A thorough assessment for the presence/absence of alcohol withdrawal should include questions about all of the following EXCEPT:
a) nausea and vomiting
b) mood
c) difficulty walking (ataxic gait)
d) visual disturbances
e) tremulousness

40. Sources Toronto Notes and MCC Practice Exams 2003
MCC Self-Administered Evaluating Examination - Online