The term "addiction" is omitted from the official DSM-5 substance use disorder diagnostic terminology

• Continued use of substance despite associated problems (except caffeine)

• Substance use disorders ➔ underlying change in brain circuits that may persist beyond detoxification

• Brain changes ➔ behavioral effects like relapses and intense craving (especially when exposed to drug related stimuli)

DX of Substance Use Disorder

2 of following within 12mo period:

Impaired control over substance

1. Larger quantity of substance/duration of use than intended

2. Persistent desire to cut down or regulate use (reports multiple unsuccessful attempts)

3. Significant time obtaining/using/recovering from use

4. Craving: intense desire or urge (could not think of anything else)

Social impairment

5. Use affects major role obligations (work/school)

6. Use causes recurrent social/interpersonal problems

7. Use ➔ given up or ↓eased activities

Risky use

8. Recurrent use in physically hazardous situations

9. Continued use despite known physical or psychological problems from use

Pharmacological criteria

10. Tolerance

    • ↑ dose required to achieve desired effect

    • OR ↓ effect with usual dose

11. Withdrawal

    • MC in etOH, opioids, sedatives/hypnotics/anxiolytics

    • ↓ SSX with stimulants, tobacco, cannabis

    • Generally not present in phencyclidine/hallucinogen/inhalant use disorder

Neither tolerance nor withdrawal is required for dx of substance use disorder

• Pharmacological tolerance and withdrawal during medical tx IS NOT "addiction"

• Medications taken as prescribed can ➔ physical dependence (dependence ≠ addiction)

• Prescription medications used inappropriately ➔ compulsive, drug-seeking behavior ➔ substance use disorder

TX for SUD is always psychosocial (CBT, 12-step groups) ± meds

• Insufficient evidence to establish diagnostic criteria and course descriptions needed to identify repetitive behaviors/excessive behavioral patterns as mental disorders

  • "sex addiction," "exercise addiction," "shopping addiction," "internet gaming addiction"

Benzodiazepines

• Main MOA: GABA agonist ➔ ↑ frequency of Cl channel opening ➔ ↑ intracellular Cl ➔ hyper-polarization ➔ ↓ neuronal excitability

• CNS depression ➔ muscle relaxant, anti-epileptic, drowsy, clumsy, anterograde amnesia (brown/blackouts)

• Addictive, causes tolerance and withdrawal

• Contraindicated in: hx of SUD, pregnancy (except for 2nd line in eclampsia), narrow angle glaucoma, myasthenia gravis

Short acting (sleep onset insomnia, sedation/induction)

• Midazolam (versed), alprazolam (xanax)

Intermediate acting (sleep onset/maintenance insomnia, status epilepticus, etOH w/d)

• Lorazepam (ativan)

Long acting (status epilepticus, etOH w/d)

• Diazepam (valium), clonazepam (klonopin), chlordiazepoxide (librium)

Diazepam, midazolam s have ↑ lipophilicity ➔ faster onset

Benzodiazepine overdose

• Lethargy/somnolence, ↓ respirations, hypotension, hyporeflexia

• Usually benzo OD is not life-threatening BUT risk of dying from OD ↑ with other substances (opioids, etOH)

• TX is generally supportive (airway protection)

  • Flumazenil is antidote to benzo OD but ➔ seizures in benzo dependent pts

    • Only use if pt is KNOW BENZO NAIVE

    • Shorter acting than benzos (so don't discharge)

Benzodiazepine withdrawal

• Sympathetic nervous system on blast ➔ anxiety, insomnia, sweating, HTN, tremors, psychosis (a/v hallucinations)

• TX is to taper dose (usually with long acting diazepam) and BOLO for seizures

Barbiturates

• Main MOA: GABA agonist ➔ ↑duration of Cl channel opening ➔ ↑ intracellular Cl ➔ hyper-polarization ➔ ↓ neuronal excitability

  • ↓ glutamate (excitatory NT)

  • Highly lipophilic ➔ rapid onset and prolonged duration of action

• CNS depression ➔ sedation, anti-epileptic, ↓ ICP

• Intra-arterial injection (accidental) ➔ vessel injury/spasm ➔ necrosis/gangrene (TX with dilution and intra-arterial lidocaine)

Rapid acting (anesthesia, ↓ICP)

• Thiopental

Short/intermediate acting (sedation)

• Pentobarbital

Long acting (Go to anti-convulsant when benzos don't work)

• Phenobarbitol

Barbiturate overdose

• Hypotension, respiratory depression/arrest, laryngo/bronchospasm

• TX is generally supportive (airway protection)

Barbiturate withdrawal

• Sympathetic nervous system on super blast ➔ delirium, HYPOtension

Melatonin receptor agonists

• Ramelteon (rozerem) binds MT1 and MT2 receptors ➔ sleepiness

• For sleep onset insomnia

Orexin receptor antagonist

• Suvorexant (belsorma) bind and ⊣ orexin receptors ➔ sleepiness

• For sleep onset/maintenance insomnia

• MOA: Inhibition of presynaptic Ca channels ➔ ↓ Ach, NE, 5HT, glutamate and inhibition of postsynaptic K channels

• Full agonists:

  • Codeine

  • Morphine

  • Hydrocodone (vicodin)

  • Oxycodone (percocet)

  • Hydromorphone (dilaudid)

  • Methadone

  • Fentanyl

• Partial agonist

  • Buprenorphine

• Full antagonists

  • Naloxone

  • Naltrexone

Opioid SSX

• CNS depression, euphoria, analgesia

• Constipation, ↓ respiration, miosis, bradycardia

• Urinary retention, hyperprolactinemia

TX opioid use disorder

Medication assisted treatment (MAT)

• • Methadone (TX chronic long-term use by replacing problematic opioid with "less euphoric and longer acting" opioid)

    • Moderate euphoria (full agonist)

    • Does not precipitate withdrawal (can use other opioids on top)

    • Typically involves visiting a clinic for daily dosing

    • Cheap

    • Can TX pts with chronic pain

  • Buprenorphine

    • Mild euphoria (partial agonist)

    • Can precipitate withdrawal (using opioids on top ➔ withdrawal sx)

      • High affinity for receptor knocks of other opiates but partial agonist doesn't give same effect ➔ w/d ssx

    • More expensive and less accessible than methadone

  • Naltrexone (vivitrol IM)

    • No euphoria (antagonist) BUT ↓ craving for opioids and etOH

    • Antagonist with long half-life and duration of action

    • Can precipitate withdrawal (using opioids on top ➔ withdrawal sx)

    • More expensive and less accessible than methadone

  • Buprenorphine/naloxone (suboxen - SL)

    • Mild euphoria

    • Partial agonist ➔ ↓ craving/antagonist ⊣ using opioids on top

    • More expensive and less accessible than methadone

Opioid overdose

• Miosis "pinpoint pupils" (<2mm), ↓ RR, ↓ HR

• TX with AIRWAY PROTECTION AND VENTILATION FIRST, if no pulse... CPR FIRST

  • Then administer naloxone (narcan) slowly (pushed too fast ➔ aggression and vomiting)

    • Naloxone duration of action is shorter than most opioids (don't discharge the pt)

Opioid withdrawal

• Anxiety, irritability, and flu like sx (myalgia, chills ➔ piloerection, rhinorrhea, yawning, diarrhea, mydriasis)

  • Withdrawal is not life-threatening but super uncomfortable

• TX is supportive

PCP (phencyclidine)

• Liquid sprayed on tobacco or cigarette dipped in (smells like magic markers)

• MOA: ⊣ 5HT, DA, NE reuptake and NMDA antagonist

PCP intoxication

• Behavior ∆ : stupor, impulsive, violent

• For some reason they get naked...

• Tachy, HTN, nystagmus

• ± miosis (most other hallucinogens cause mydriasis)

• BOLO seizures, rhabdo, and agitation/psychosis

TX

• Benzos or haldol for agitation

Phenethylamines

• Amphetamine, meth-amphetamine, MDMA, mescaline

• MOA: Depending on functional groups added to amphetamine: 5HT/D2 agonists, DART antagonist

• MDMA ➔ ↑ ADH secretion

  • Excess water intake ➔ hypoNa (have to drink gatorade when taking molly)

Intoxication

• Euphoria, agitation, insomnia, diaphoresis

• Tachy, HTN, bruxism (teeth grinding)

• Hyperthermia

• MDMA can ➔ serotonin syndrome

• Methamphetamine can ➔ delusional parasitosis (bug infestation)

TX

• Benzos or haldol for agitation

• Control hyperthermia (>41.1)

  • Control excessive muscle activity (usually controlled with sedation) and aggressive cooling

  • Severely intoxicated may require paralytics and airway control: use nondepolarizing agents (rocuronium)

    • Succinylcholine is relatively contraindicated (↑ risk of rhabdo)

  • ANTIPYRETICS (Tylenol) does NOT help hyperthermia from amphetamine intox

• Control tachy, HTN and BOLO arrhythmias

  • Sedation generally controls tachy and HTN but

    • If HR >180: diltiazem

    • If severely hypertensive: use nitroprusside or NTG

    • Avoid β-blockers

• Over 100 cannabinoids (bind cannabinoid receptors) present in marijuana

  • ∆ 9-TetraHydroCannabinol (THC) is most psychoactive active

  • Binds cannabinoid receptors CB1 and CB2 ➔ adenylate cyclase inhibition

• Medical marijuana - dronabinol

Marijuana intoxication

• Euphoria, distorted sense of time, joviality (laughing)

• Can cause anxiety/paranoia

• ↑ appetite (munchies) junk food junky - potato chips and lunch meat, up in the front seat

• Dry mouth, conjunctival injection (red eyes), ± mydriasis

• Associated with psychosis and development of schizophrenia - pot ➔ schizophrenia OR schizophrenia ➔ self-medication (chicken or egg)

• Long-term use can ➔ cannabinoid hyperemesis syndrome

  • ABD pain, N/V ± relieved with hot water exposure (shower/bath)

  • TX is cessation

• Tobacco use is bad...

• Smoking if a RF for most things

• Smoking is protective for UC

• TX: Bupropion (Wellbutrin), nicotine replacement (patch, gum, lozenges)

• Persistent and recurrent problematic gambling ➔ impairment or distress

• Gambling problem is NOT from/during manic episode

• At least 4 in 1 year:

  • Needs to ↑ amount gambled for effect

  • Restless or irritable when attempting to cut down/stop

  • Unsuccessful efforts cut down/stop

  • Preoccupied with gambling

  • Gambles when feeling distressed

  • Returns after losing money to "get even"

  • Conceals extent of gambling (lies about how much)

  • Jeopardizes/lost significant other/job/opportunity

  • Relies on others to relieve desperate financial situation

TX

• • 12-step program, CBT