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Psych D&A

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imo132's version from 2016-11-20 02:22

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Question Answer
Methadone under 18Needs second opinion from approved prescriber, court order for under 16
Heroin preg compPremature labour, miscarriage, infx, IUGR, hypoxia, PPH, APH
Bupren in pregNot recommended, cannot be used in breastfeeding
EtOH withdrawal RxDiaz q2h, thiamine IM/IV if Wernicke's suspected for 5 days, metoclopramide for vomiting
Heroin withdrawal RxBuprenoprhine for 5 days, diaz if insomnia
Stimulant withdrawal RxDiazepam, olanzapine/quetiapine if psychotic
Benzo withdrawal RxFlumazenil or diaz dose equivalents, taper by 10-20% daily
Cannabis withdrawal RxMirtaz for insomnia, diaz for restlessness
AWSPerspiration, tremor, anxiety, agitation, hallucinations, axillary temp, orientation
Opioid withdrawal RxBuprenorphine for 5 days
Methadone -> subutexMay cause 2 weeks dysphoria, lower methadone to 40 mg first
EtOH intoxicationSlurred speech, disinhibition, ataxia, blackout, impaired judgement
EtOH withdrawal SxHTN, tachycardia, seizures, psychosis, hallucinations, delirium tremens
Benzo intoxicationDelirium in elderly, low RR, coma, amnesia
Benzo withdrawal SxHTN, tachycardia, seizures, psychosis
Opiate intoxicationEuphoria, pupil constriction, low RR, track marks
Opiate withdrawal SxYawning, lacrimation, sweating, itching, pain, mydriasis, piloerection, dysphoria, nasal stuffiness, N&V, diarrhea, abdo pain, leg cramps, sleep disturbance no seizures or hallucinations
Opiate withdrawal RxNaloxone acutely (inverse agonist), methadone chronically
Opiate overdose SxDrowsy, slurred speech, N&V, miosis, flushing, sweaty skin, decreased RR, HR, BP, seizures, pulmonary oedema
Opiate overdose RxNaloxone
ToleranceLowering of activity of reward pathway
Opioid RxNo benefit with detox, relapse common afterwards, methadone best (50% still using at 12 months), then buprenorphine (35% at 12 months), increase in death in 1st month after ceasing Rx
Opioid Rx effectiveness<75% cease heroin with Rx, 1/3 have sustained abstinence
Cocaine intoxicationPsychomotor agitation, HTN, tachycardia, psychosis, dilated pupils, angina, HTN crisis
Cocaine withdrawal SxDepression, formication
Cocaine withdrawal RxAlpha blockade
Amphetamine intoxicationDilated pupils, psychosis, overheating (fever, tachycardia), water intoxication
Amphetamine withdrawal SxCrash, depression, Rx is supportive
Frontal assessmentsIn what way are (banana & orange) alike? Say as many words as you can beginning with the letter S, fist/edge/palm
Thiamine Rx100 mg IM tds 3 days then 100 mg PO 1 week
Alcohol withdrawal score<8 mild, 8-25 moderate to severe, >25 very severe
Alcohol withdrawal scale7 criteria every 30-60 minutes until stable, agitation, orientation, hallucination, sweating, anxiety, tremor, temperature
IceMethamphetamine, in 0.1 gram quantities, quantify in dollar amount
Smoking deathOf those who smoke, 50% die from the smoking (most common cause of death in smokers), protects against parkinsons
Nicotine levelsHighest in schizophrenics, most have 30-40 ng 2 mins after cigarette
Nicotine patches21 mg patch gives 10 ng to body (too low)
a4b2a5Dependence receptor
ChampixVarenicline, NRT drug, uses a4b2 receptor, partial nicotine agonist
CYP2A6Metabolises nicotine
Fast CYP2A6Smoke more, more addicted, increased lung cancer risk, NRT ineffective, inhale deeper so higher CO, in pregnant, mediterranean, european, females
Slow CYP2A6Asian, African American, smoke less
CYP1A2Induced by PAHs from cigarettes, causing increased caffeine metabolism & increased coffee intake
Cigarettes & caffeineSmoking causes tolerance, cessation causes toxicity
Smoking & toleranceNeed more insulin, narcotics, APs, warfarin, caffeine, alcohol, monitored if quitting (hypoglycemia common as need less insulin)
Smoking & alcoholLowers BAC, increases alcohol tolerance (metabolise alcohol faster)
Smoking withdrawalCravings, anxiety, tension, aggression, high appetite, inability to concentrate, depression, ulcers, constipation, severe in 1st week, last days-weeks, relapse 2nd week
Smoking withdrawal RxUse 2 of varenicline, burpropion & NRT
Nicotine patchesTake hours to work, no wearing off, combination better, can smoke, apply at night to peak in morning, CO level used for titration, better in women
9THC2-arichidonyl glyerol, CP 55940
8THCAnandamide, HU 210, most potent, 100x THC
CB1 receptorBrain & periphery, for cannabinoids, antagonised by Rimonabant
CB2 receptorImmune system, for cannabinoids
RimonabantCB1 antagonist, anti-obesity drug
SativexMouth spray with THC & CBD (cannabidiol) extract
DronabindPure THC extract
THC medical useAnti-spasticity & neuropathic pain in MS, antiemetic (low efficacy), appetite stimulant, analgesic, substance dependence (but causes depression)
Marijuana in naiveDysphoria, psychotic Sx, paranoia, unpleasant feeling, respiratory risk
Mairjuana in regularsLow risk of respiratory Sx, high risk of dependence, smoke fewer darts but more effectively
Marijuana effectsEuphoria, relaxation, increased appetite, disinhibition, vasodilation, bronchodilation, relieves negative Sx of schizophrenia, low risk taking, high MVA risk
Marijuana SEAnxiety, dysphoria, panic, paranoia, psychomotor impairment, psychotic Sx at high doses
Marijuana long termChronic bronchitis, wheeze, dyspladsia, impaired pulmonary Mo, increased health service use, no decline in respiratory function
Toxic psychosisOnly occurs during intoxication
Functional psychosisPersists after intoxication, substance precipitates & exacerbates psychosis
Psychosis & THCSchizophrenics have more anandamide in CSF & more CB1 receptors
Marijuana dependenceOnly in <50% daily users
Marijuana withdrawalWorst in 1st week, with irritability, anger, restlessness, anxiety, sleep difficulty, appetite change, craving, depressed mood
Marijuana withdrawal RxBenzos, satives (nabiximols), brief intervention, counselling
Alcohol epidem3rd highest cause of death & disability
Alcohol withdrawalOnset 6-24 hours after last drink, peaks 24-48 hours, lasts 4-6 days, low GABA, high glutamate, severity predicted via past withdrawal severity, prior seizures, amount of alcohol consumed, morning eye-opener needed
Alcohol withdrawal SxInsomnia, morning irritability, sweating, tachycardia, tremor, anxiety, GIT disturbance, seizures, N&V
Early alcohol withdrawal6-48 hours, with seizures, 25% recurrence in next 6-12 hours, in <10% alcohol dependent
Late alcohol withdrawal36 hours-5 days, delirium tremens (tremors, hallucinations, anxiety, disorientation), in 5% alcohol dependent
FeedbackNo more than 2 drinks per day for long term prevention, 4 for short term prevention
Safe alcohol useBottle wine for 6 people, cask for 10, slab for 9, 1 longneck each, 2 cans, 2 stubbies
Dependence Sx3 of withdrawal, loss of control, craving, continued use despite harm, salience, tolerance
DrinklessIntervention for non-ATSI drinkers
Drug-seekersFrom >6 prescribers, 25 target drugs or >50 drugs in total over 3 months, 3% of patients, 10% misuse prescription drugs, age 20-40, M=F
Trends in drug seekingTramadol available 2000, peak 2005, morphine, oxycodone & fentanyl increase, morphine stable
Opioid overdose1-2% mortality per year, risk increased with benzo & EtOH use, less heroin overdose, most using heroin also use prescription meds
Opioid epidem3% mortality per year (from heroin), overdose in young, liver disease & HIV in old, with vein damage, low mood, more ED presentations if more opioid in community
Opioid dependenceUsed not for euphoria but to prevent withdrawal
Opioid dosingIV bolus or smoking delivers most to CNS, is most reinforcing method
HyperthermiaFrom MDMA on hypothalamus, disrupts ability to regulate temperature
MethadoneLong acting opioid agonist, decreases withdrawal, increased clearance leads to low mood & higher drug use, most deaths from people not on program
Methadone dosing40 mg/day prevents withdrawal & gives reinforcing effects, higher doses increase tolerance (if injecting heroin, need more – actually increases use)
Substitution treatmentControlled supply (methadone), stabilization (to prevent withdrawal), diminish reinforcing effects, structure (attendance & monitoring)
Methadone initiationHigher risk of death initially due to misjudged tolerance, slow metabolism, benzo, TCA, alcohol use, increase by 10 mg weekly
BuprenorphineHigh mu affinity, partial agonist, less tolerance, safer in overdose as less resp depression, flat dose-response curve
SpeedAmphetamine sulfate or methamphetamine, for euphoria, increased libido & appetite, enactogen/empathogen (friendly), methyl group increases availability & potency
Speed mechanismBlocks reuptake transporter DAT, inhibits UMAT & MAO to increase DA
MDMADirect GABA-B agonist, metabolized to GABA, at low conc stimulates GHB-R (stimulant), at high conc stimulates GABA-R (depressant), highest DA release of all, GHB is liquid ecstasy, 30-60 min half life
MDMA overdoseCNS depression, hypoventilation, aspiration
GBLSimilar to MDMA but more lipid soluble, increased bioavailability & shorter half life
Stimulant harmLeast harm from ecstasy, most from crack cocaine, most user polydrug users, most admitted to hospital due to psychosis
Stimulant psychosisTactile (formication), visual (snow lights), labile affect, orientated, no insight
Stimulant SESympathomimetic syndrome (dilated pupil, high HR, tremor), seizure, hyperthermia, HTN, AMI, CVA, reverse takotsubo (cardiomyopathy), rhabdo, AKI, crack lung (if smoked), hyponatremia (MDMA), pneumothorax/pneumomediastinum (cocaine)
IceMethamphetamine, immediate onset if IV, 30 min if oral, 5-12 hour half life, in urine up to 48 hours, most users 20-29
Methamphetamine SEHTN, cardiotoxicity, arrhythmias, MI, heart failure, dissection, stroke, dehydration, hyperthermia, SIADH, seizures, 5HT syndrome, agitation, psychosis, delirium
CocainePure alkaloid (base), hydrochloride (salt), NaCO3 (crack), $280/g or $50/cap, 30-60 min onset, 1 hour half life (BE 6-8 hours), in urine up to 48 hours, only 40% pure on average
Cocaine + EtOHMakes cocaethylene, has longer half life & more affinity for DAT than cocaine (more effects)
Stimulant Rx5 year gap to treatment, more likely to seek help if risky use, mental illness, male, born in Aus, unemployed, injector, use bupren, methyphenidate, D-amphetamine, risperidone, naltrexone, rivastigmine, varenicline
Schedule 8Must have govt authorisation for all drug-dependents or for non-dependents for more than 2 months (except if sustained release)
Govt authorisationRequired for schedule 8 for drug dependent or non dependent but for >2 months (not if sustained release)
Govt authorisation drugsDexam, methylphen, bupren, flunitr, alprazolam, hydromorphine, methadone, injectable to anyone for > 2 months
Separate authority drugsFor methadone liquid & subutex/suboxone
Drug abuseAnalgesics > tranquilisers > sleeping pills, most opioid abuse from OTC drugs
Alcohol epidem25% abstinent >3 years, 25% dead, 25% ongoing alcohol problem, 25% drinking without problems
Prognosis off alcoholPredicted via premorbid stability, sustained abstinence, AA attendance
Alcohol withdrawal RxLong acting benzos, PRN, IV thiamine as needs increase in withdrawal
Wernicke'sConfusion (most sensitive Sx), ataxia, nystagmus, ophthalmoplegia
KorsakoffAnterograde & retrograde amnesia, apathy, confabulation
NaltrexoneRivia, opioid antagonist, od for adherence, contra if LFTs x5 or opioid use
Naltrexone useUsed in "reward drinkers", those with FHx (OPRMI), effective if started before/after withdrawal, decreases heavy drinking days
Naltrexone mechanismInhibits release of endogenous opioids to inhibit reward pathway
Alcohol rewardEndogenous opioids released via EtOH inhibit GABA release from VTA, disinhibiting release of dopamine from nucleus accumbens & causing reward
AcamprosateCampral, 666 mg tds (less adherence), NMDA antagonist & GABA elevator, anti-craving, start when abstinent, contra creatinine >120, liver failure
Acamprosate useEffective if started after withdrawal commenced (not while drinking), maintains abstinence, for withdrawal-avoidant drinkers
DisulfiramNon-PBS, 200 mg od, inhibits AcetADH & b-hydroxylase, anti-craving by inducing sweating, abdominal pain, flushing, contra liver disease & varices, resp/cardiac disease, start 4 days after last drink, stop 2 weeks before next drink
Disulfiram useTo prevent craving in abstinent & motivated patients with someone to supervise them, induces negative association with alcohol
Disulfiram for alcoholInhibits acetald DH, causing flushing, tachycardia, SOB, N&V, headache, blurred vision, confusion, hangover Sx
Disulfiram for cocaineInhibits DA conversion to NA via dopa-decarboxylase, thereby increasing DA & producing unwanted anxiety
Alcoholics anonymousBest for social drinkers
Recovery from alcoholAchieved in 60%, early withdrawal/stabilisation in phase I (weeks), early remission in phase II (year), sustained remission in phase III (5 years until risk of relapse plateaus)
CHIMEAlcohol strategy, involves connectedness (men's sheds, prevent isolation & boredom), hope, identity, meaning, empowerment
Health in alcoholicsStable abstainers have better health than the normal population due to better attitude & resources
Stimulant epidem35% college students, peak use 16-19,
Crime & drugsMarijuana > methamphetamine > benzos
Morphine trafficking100 mg doses, buy for $5.30, sell for $1600
Opioid referralIf dose exceeds 100 mg oral morphine equivalents, prescribed by specialist only, use slow-release rather than short half-life drugs, no injectables
BupropionAtypical AD (NDRI) for smoking cessation, reduces cravings & withdrawal symptoms, as effective as NRT but less than varenicline, start before ceasing
Benzo durationDiazepam > clonazepam > lorazepam > temazepam
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