Addiction PsychiatryMartina Smit, MDTheresa LoSept 18, 2015

Objectives• Overview of addiction:

• neurobiology• DSM5 criteria for substance use disorders• specific substance syndromes

• Assessment• Substance use history

• Treatment options, resources

Addiction:

A primary, chronic disease of • Brain reward• Motivation• Memory, and related circuitry

American Society of Addiction Medicine

REWARD CIRCUITRY

Associative learning High significance to substance,Substance-rel’d cues

Marks salience of rewardSignals rewarding eventWill occur

http://neurowiki2012.wikispaces.com/file/view/Reward_circuit.jpg/315908202/Reward_circuit.jpg

Neurotransmitters and Effects Dynorphin: dysphoria Dopamine: dysphoria

CRF: stress Serotonin: dysphoria

Norepinephrine: stress GABA: anxiety, panic attacks

Glutamate: hyperexcitability Opioid peptide: dysphoria

Koob GF, Simon EJ. The Neurobiology of Addiction: Where We Have Been and Where We Are Going. Journal of drug issues. 2009;39(1):115-132.

SUBSTANCE-RELATED AND ADDICTIVE DISORDERS

General diagnostic criteria

DSM5 Substance Use disorder2 or more in 12 months:• Larger amts/longer

period than intended• Persistent

desire/unsuccessful efforts to cut down

• A great deal of time spent to obtain, use, recover

• Craving• Recurrent use fail to

fulfill major role obligations

• Continued use despite problems due to substance

• Important activities given up or reduced

• Recurrent use in physically hazardous situations

• Continue use despite knowledge of phys or psychol problems

• Tolerance• withdrawal

Severity• Mild: 2-3 symptoms• Moderate: 4-5 symptoms• Severe: 6+ symptoms

Physiologic dependenceTolerance

• need more for same effect; • or, less effect with same

amount

Withdrawal

• characteristic syndrome; • Or, take same or similar

substance to avoid it

SPECIFIC SUBSTANCE SYNDROMES

Alcohol intoxication

• Slurred speech• Dizziness• Incoordination• Unsteady gait• Nystagmus• Impairment in attention or memory• Stupor or coma

- Many receptors involved

Alcohol: low risk use

• Men <65yo• No more than 3 drinks/day AND• No more than 15 drinks/week

• Women <65yo• No more than 2 drinks/day AND• No more than 10 drinks/week

• Special occasions:• No more than 4 drinks at a time for men• No more than 3 drinks at a time for women

Alcohol withdrawal: (2 or more)

• Autonomic hyperactivity• Increased hand tremor• Insomnia• Nausea or vomiting• Transient hallucinations (visual, tactile, auditory)• Psychomotor agitation• Anxiety• Grand mal seizures• Delirium tremens

Alcohol withdrawal mgmt• Inpt vs outpt• Benzos

• Fixed-dose vs symptom-triggered (CIWA)• Thiamine IM, multivitamins• Investigations?

• CBC, Lytes incl K, Mg, LFTs, INR, BAL

Cannabis intoxication

1. Behavioral or psychological changes• Lower doses:

• Relaxation, euphoria, altered time/sensory perception; • Higher doses:

• Hypervigilance/paranoia; anxiety/panic; derealization/depersonalization; hallucinations

2. 2 or more of: Conjunctival injection, increased appetite, dry mouth, tachycardia

***chronic THC use in youth associated with psychosis/schizophrenia

-acts on cannabinoid receptors (found throughout CNS)

Cannabis withdrawal• 3 or more:

• Irritability, anger or aggression• Nervousness or anxiety• Sleep difficulty (insomnia, disturbing dreams)• Decreased appetite or wt loss• Restlessness• Depressed mood• At least 1 phys sx: abdo pain, tremors, sweats, fever, chills, HA

Stimulant intoxication 2 or more

• Tachycardia or bradycardia• Pupillary dilation• Elevated or lowered BP• Perspiration or chills• Nausea or vomiting• Wt loss• Psychomotor agitation or retardation• Muscle weakness, respiratory depression, chest pain,

arrhythmias• Confusion, seizures, dyskinesias, dystonias, or coma

Mechanism: cocaine: Monoamine reuptake inhib; Amphet: MAO inhib, DA+NE release

Stimulant Withdrawal

“Crashing”• Dysphoria• 2 or more of

• Fatigue• Vivid, unpleasant dreams• Insomnia or hypersomnia• Increased appetite• Psychomotor retardation or agitation

Opioid intoxication• Pupillary constriction (or dilation due to anoxia in severe OD)

AND• Drowsiness or coma• Slurred speech• Impairment in attention or memory

***OD life-threatening respiratory depression

Opioid withdrawal

Early to Moderate

• Anorexia• Anxiety• Craving• Dysphoria• Fatigue• Headache• Irritability

acrimation

Moderate to Advanced

• Abdo cramps• Broken sleep• Hot/cold flashes• Incr BP• Low-grade fever• Muscle/bone pain• Muscle spasm “kick the

habit”• Mydriasis • Nausea, vomiting

Mydriasis (mild)

Perspiration

Piloerection “cold turkey”

Restlessness

Rhinorrhea

Yawning

Burgeois J et al Eds 2012

Sedative-Hypnotics• Barbiturates

• Lethal in OD• Benzos

• Bind to bzd receptors, enhance GABA• Z-drugs (zopiclone)• Intoxication and withdrawal similar to alcohol

Hallucinogens (LSD, others)

• LSD interferes with serotonin neurotransporters• Psilocybin, mescaline, [mdma]• Intoxication (2 or more):

• Pupillary dilation blurred vision• Tachycardia tremors• Sweating incoordination• palpitations

PCP, ketamine• Antagonize NMDA glutamate receptors• Intoxication (2 or more):

• VERTICAL or horizontal nystagmus• HTN or tachycardia• Numbness, diminished responsiveness to pain• Ataxia• Dysarthria• Muscle rigidity• Seizures or coma• hyperacusis

Inhalant intoxication (2 +)

• Dizziness• Nystagmus• Incoordination• Slurred speech• Unsteady gait• Lethargy• Depressed reflexes

• Psychomotor slowing• Tremor• Generalised muscle

weakness• Blurred vision or

diplopia• Stupor or coma• euphoria

A 43yo F is brought to ER after becoming aggressive with a police officer during a routine traffic stop. She is noted to be extremely argumentative, with a labile mood. She makes several sexually inappropriate remarks to the examining physician. Examination reveals an unsteady gait, slurred speech, nystagmus and flushed face. The patient is afebrile, HR 78, respiratory rate 24/min. This pt’s presentation is most consistent with acute intoxication from which of the following?A. AlcoholB. CannabisC. CocaineD. HallucinogensE. Opioids Focus 2011

A 32yo M is brought to the ER after sustaining a generalised tonic-clonic seizure. Pt it noted to be hypervigilant and extremely abusive and aggressive. He suspects that the technicians may be taking blood samples from him for illegal purposes. He complains of nausea. Past medical hx is unremarkable and the pt is currently taking no meds. Examination reveals pt to be diaphoretic. He is afebrile, pulse 124, respirations 28 and BP 164/96. Pupils are dilated, but reactive to light. The pt’s presentation is best explained by acute intoxication from which of the following?A. AlcoholB. CannabisC. CocaineD. HeroinE. Phencyclidine Focus 2011

ASSESSMENT

Screening• All pts presenting for substance use treatment should be

screened for co-occuring MH disorders• All pts presenting for MH treatment should be screened for

co-occurring substance use disorders

CAGE Questionnaire

• Have you ever felt you should cut down on your drinking? • Have people annoyed you by criticizing your drinking? • Have you ever felt bad or guilty about your drinking? • Have you ever had a drink first thing in the morning to steady

your nerves or to get rid of a hangover (eye opener)? • Scoring: Item responses on the CAGE are scored 0 or 1, with a

higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant.

Copyright: © American Psychiatric Association

Substance Use HX: TRAPPED• Treatment History (detoxification, treatment programs,

medications, 12-step programs)• Route of administration (smoked, orally ingested, snorted,

inhaled/"huffed," injected IV/IM/SC)• Amount (money spent, "pills," "bags," "vials," grams, ounces per

bottle, frequency)• Pattern of use (binge, daily, solitary, period of heaviest use, etc.)• Prior abstinence (duration, what has helped in past, both in and

out of a controlled environment)• Effects (direct and indirect, adverse, physical, social, legal,

positive, withdrawal,etc.)• Duration of use (age of first use, most recent use)

Welsh CJ. Academic Psychiatry 2003:27:289

Stages of change Prochaska & DiClemente 1992

Physical Exam

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/drug-abuse-and-addiction/Default.htm

TREATMENTMeds

Alcohol• Naltrexone• Acamprosate• Disulfiram• Possibly (some evidence): topiramate, baclofen

Opioids• Methadone• Buprenorphine• Symtomatic trx (e.g. Clonidine, ibuprofen, tylenol, lorazepam,

phenergan, imodium)

Nicotine• NRT (gum, patch, inhaler, spray)• Bupropion• Varenicline

• 42yo F is started on a medication for alcohol dependence. At a party, she decides to have one drink. Shortly thereafter, she becomes nauseated, tachycardic, and hypertensive with marked facial flushing. The medication was most likely:

• A. Acamprosate• B. Naltrexone• C. Disulfiram• D. Naloxone

TREATMENTPsychosocial

Psychosocial• CBT• Motivational enhancement• 12-step• Interpersonal therapy• Family/group/marital• Self-help• Case management

Treatment settings• Outpatient• Day programs• Residential• Recovery houses…

• A patient with alcohol dependence is referred for substance treatment by his family practitioner. The patient is not sure his drinking is that problematic. Which of the following would be the best initial approach?

• A. motivational interviewing• B. CBT• C. Psychodynamic psychotherapy• D. Supportive psychotherapy• E. 12-step program Focus 2011

• A 45yo Caucasian single M mechanical engineer has a two-year history of depression and 20 years of problematic alcohol consumption. He has found 12-step programs partially helpful for his drinking, but is now motivated to receive a professional, integrated approach to managing both his depression and drinking. He has researched treatment options and would like to try a course of CBT and medication. Which one of the following is the best medication approach to address his depressive sx and addictive behavior?

• Lorazepam only• Naltrexone and sertraline• Naltrexone only• Sertraline and lorazepam• Sertraline only Focus 2011