Substance Use Disorders

Substance Use Disorders-
-Abuse-
-Substance use disorder can be recognized when a patient requests help to discontinue the use of alcohol or drugs

-Risky use of alcohol or other drugs when consumption amounts that increase the likelihood of health consequences

-Substance Use Disorder replaced the psychiatric diagnoses once known as substance dependence and substance abuse

-Physical dependence is a state of adaption manifested by a withdrawal syndrome that is produced with an abrupt cessation of a substance or by tolerance to a substance

-Addiction-is a primary, chronic, neurologic disease, with genetic psychosocial and environmental factors influencing its development and manifestations.   Addiction is characterized by behaviors that include impaired control over substance abuse, compulsive use, and continue despite harm and craving

-Unhealthy Alcohol or Other Drug Use-refers to the spectrum that can result in health consequences

-Various types of substance use and approach to treatment

-Cocaine use and intoxication is treated with supportive care such as benzodiazepines to control agitation.

-Cocaine symptoms are best treated by allowing the patient to sleep and eat as needed in a supportive environment

-No medication has shown to be effective in cocaine withdrawal syndrome

-Psychosocial treatment is best for cocaine use and have shown to lead to mean reductions in cocaine use.  No medication has been shown to be effective in cocaine dependence

-Patients with opioid use disorder wan achieve abstinence though medically supervised withdrawal often require long treatment to prevent relapse

-Long term treatment of opioid use disorder may take several forms:
1.  Psychosocial treatment and abstinence based treatment can be provided in the outpatient setting
2.  Opioid antagonist treatment-naltrexone base therapies exist that are antagonistic to opioids
3.  Opioid agonists treatment with methadone, buprenorphine can be given to patients and then wean them down.  Not ideal

-Opiate withdrawal is characterized by pupillary dilation, yawning, increased bowel sounds, and piloerection.  Patients may have severe distress, heart rate, blood pressure and respiratory rate may be increased.  Patients may present with volume depletion from vomiting and diarrhea.

 -Other symptoms of opiate withdrawal include rhinorrhea and lacrimation, myalgia, arthralgia, and abdominal cramping

-Opiate withdrawal can occur within 6 hours of discontinuation of use

-Abstinence detoxification from opioids is largely supportive with hydration and control of symptoms such as vomiting, and agitation.  Phenergan and Atarax are commonly used for control of symptoms.

-Benzodiazepine withdrawal onset may vary from the half life of the particular benzodiazepine involved.  Symptoms may be delayed up to three weeks after discontinuation

-Symptoms of benzodiazepine withdrawal can include tremors, anxiety, perceptual disturbances, dysphoria, seizures, and psychosis

-BZD withdrawal is treated with a BZD that has a prolonged clinical effect, such as valium IV and titrated to the desired effect

-The BZD does should be tapered gradually over a period of months.  BZD withdrawal can be fatal if not treated appropriately

-Alcohol withdrawal can present with a variety of symptoms

-Minor alcohol withdrawal symptoms include insomnia, tremulousness, mild anxiety, gastrointestinal upset, anorexia, headache, diaphoresis and palpitations

-Alcohol withdrawal seizures are generalized tonic clonic seizures and usually occur within 12-48 hours of their last uses

-Alcohol hallucinosis and delirium tremens (DT) are not synonymous.  Hallucinations are usually visual, although auditory may occurred can develop within 12-24 hours of last use and usually resolve within 24-48 hours

-DT is associated with global clouding of the sensorium with specific hallucinations and vital signs are normal

-Treatment of psychomotor can be done with benzodiazepines such as librium, ativan, or valium

-Thiamine and glucose should be administered to prevent Wernicke's encephalopathy

-Ativan or Serax should be used of patients with cirrhosis or acute alcoholic hepatitis

-Patients with moderate to severe alcohol withdrawal should be admitted to the ICU for monitoring and treatment

-Antipsychotics including haldol should not be used because they lower seizure threshold