Substance use disorders Notes

NOTES NOTES SUBSTANCE USE & RELATED DISORDERS GENERALLY, WHAT ARE THEY? PATHOLOGY & CAUSES ▪ Maladaptive pattern of substance use ▪ Dependence: inability to feel “normal” without using substance ▪ Addiction: compulsive substance use to achieve reward stimuli, despite negative effects ▪ Continued consumption causes tolerance ▫ Receptors become less sensitive, or neurons have fewer receptors (downregulation) ▫ Must consume more of substance to feel desired effect (positive reinforcement) ▪ Stopping use causes withdrawal ▫ Body predictively counters consumption symptoms; no consumption = nothing to counter ▫ Must consume more to avoid discomfort (negative reinforcement) ▪ Possibly fatal complications (e.g. cancer, heart attack, overdose) SIGNS & SYMPTOMS ▪ Increased tolerance ▪ Upon withdrawal ▫ Anxiety, depression, irritability, fatigue, tremors, palpitations, clammy skin, dilated pupils, sweating, headaches, difficulty sleeping, vomiting, seizures, changes in vital signs 748 OSMOSIS.ORG DIAGNOSIS OTHER DIAGNOSTICS ▪ ≥ two of following ▫ Consuming more of a substance than intended ▫ Inability to cut down ▫ Use takes up a lot of time ▫ Cravings ▫ Use affects responsibilities ▫ Using in spite of social problems caused ▫ Use replaces important activities ▫ Using in physically dangerous situations ▫ Using even if it worsens a problem ▫ Developing tolerance ▫ Feeling withdrawal symptoms ▪ Mild = 2–3 symptoms, moderate = 4–5 symptoms, severe = ≥ 6 symptoms TREATMENT MEDICATIONS ▪ To reduce cravings, mimic substance, or change its effects PSYCHOTHERAPY ▪ E.g. motivational interviewing, cognitive behavioral therapy, peer-support programs

Chapter 104 Substance Use & Related Disorders ALCOHOL USE DISORDER osms.it/alcohol-use-disorder PATHOLOGY & CAUSES ▪ Inability to feel “normal” without alcohol ▪ Alcohol use disorder: maladaptive pattern of alcohol consumption ▪ Alcohol = depressant ▪ Develop alcohol tolerance ▫ GABA, glutamate, dopamine, serotonin receptors become less sensitive/neurons have fewer receptors (downregulation) ▫ Must drink more to feel euphoric (positive reinforcement) ▪ Withdrawal COMPLICATIONS ▪ Heart damage (dilated cardiomyopathy, arrhythmias, stroke), liver damage (steatosis, steatohepatosis, fibrosis, cirrhosis), pancreatitis, cancers (mouth, esophagus, throat, liver, breast), death by overdose (cardiac, respiratory depression) SIGNS & SYMPTOMS ▪ Increased alcohol tolerance ▪ Upon withdrawal ▫ Anxiety, depression, irritability, fatigue, tremors, palpitations, clammy skin, dilated pupils, sweating, headaches, difficulty sleeping, vomiting, seizures ▫ Delirium tremens (high fever, hallucinations, intense agitation) MNEMONIC: CANs of beer Wernicke-Korsakoff triad Confusion Ataxia Nystagmus DIAGNOSIS OTHER DIAGNOSTICS ▪ ≥ two of following ▫ Consuming more alcohol than intended ▫ Inability to cut down ▫ Alcohol use takes up a lot of time ▫ Cravings to use alcohol ▫ Alcohol use affects responsibilities ▫ Using alcohol despite social problems ▫ Giving up important activities for alcohol ▫ Using alcohol in dangerous situations ▫ Using alcohol even if worsens a problem ▫ Becoming tolerant to alcohol ▫ Withdrawal symptoms ▪ Mild = 2–3 symptoms, moderate = 4–5 symptoms, severe = ≥ six symptoms TREATMENT MEDICATIONS ▪ Naltrexone (reduces cravings), acamprosate (stabilizes withdrawal), disulfiram (increases ethanol sensitivity) PSYCHOTHERAPY ▪ Motivational interviewing, cognitive behavioral therapy, peer-support programs MNEMONIC: COAT RACK Wernicke’s encephalopathy Confusion Ophthalmoplegia Ataxia Thiamine tx. Korsakoff’s psychosis Retrograde amnesia Anterograde amnesia Confabulation Korsakoff’s psychosis OSMOSIS.ORG 749

Figure 104.1 Illustration showing alcohol’s effects on the hypothalamus, pituitary glands, and medulla. Figure 104.2 Illustration showing the effects of alcohol withdrawal. CANNABIS DEPENDENCE osms.it/cannabis_dependence PATHOLOGY & CAUSES ▪ Inability to feel “normal” without cannabis ▪ Cannabis use disorder: maladaptive pattern of cannabis use ▪ Cannabis = depressant/stimulant 750 OSMOSIS.ORG ▪ Continued cannabis use causes tolerance ▫ Cannabinoid receptors become less sensitive/neurons have fewer receptors (downregulation) ▫ Must consume more to feel euphoric (positive reinforcement) ▪ Withdrawal

Chapter 104 Substance Use & Related Disorders COMPLICATIONS ▪ Anxiety, depression, psychotic disorders (e.g. schizophrenia), hyper-inflated lungs (when smoking cannabis), chronic bronchitis, respiratory infections, heart attacks, strokes ▪ Teenagers at higher risk (developing brain more sensitive) SIGNS & SYMPTOMS ▪ Increased cannabis tolerance ▪ Upon withdrawal ▫ Cravings, irritability, anxiety, difficulty sleeping ▫ Giving up important activities for cannabis ▫ Using cannabis in dangerous situations ▫ Using cannabis even if it worsens a problem ▫ Becoming tolerant to cannabis ▫ Withdrawal symptoms ▪ Mild = 2–3 symptoms, moderate = 4–5 symptoms, severe = ≥ six symptoms TREATMENT PSYCHOTHERAPY ▪ Motivational interviewing DIAGNOSIS OTHER DIAGNOSTICS ▪ ≥ two of following ▫ Consuming more cannabis than intended ▫ Inability to cut down ▫ Cannabis use takes up a lot of time ▫ Cravings to use cannabis ▫ Cannabis use affects responsibilities ▫ Using cannabis despite social problems Figure 104.3 Illustration showing the stimulant effects of tetrahydrocannabinol (THC) versus the depressant effects of cannabidiol (CBD). CBD’s properties mean it can be used medicinally in some cases. OSMOSIS.ORG 751

Figure 104.4 Illustration showing the potential physical and mental effects of severe cannabis dependence. COCAINE DEPENDENCE osms.it/cocaine-dependence PATHOLOGY & CAUSES ▪ Inability to feel “normal” without cocaine ▪ Stimulant use disorder: maladaptive pattern of stimulant use ▪ Cocaine = stimulant ▪ Continued cocaine use causes tolerance ▫ Dopaminergic receptors become less sensitive/neurons have fewer receptors (downregulation) ▫ Must consume more to feel euphoric (positive reinforcement) ▪ Withdrawal COMPLICATIONS ▪ Hyperthermia, seizures, stroke, brain hemorrhage, heart attack, death by overdose 752 OSMOSIS.ORG SIGNS & SYMPTOMS ▪ Increased cocaine tolerance ▪ Upon withdrawal ▫ Depression, anxiety, fatigue, reduced concentration, cravings, tiredness, increased appetite, excessive sleeping, vivid dreaming, suicidal ideation, nausea, vomiting, hallucinations DIAGNOSIS OTHER DIAGNOSTICS ▪ ≥ two of following ▫ Consuming more stimulants than intended ▫ Inability to cut down ▫ Stimulant use takes up a lot of time ▫ Cravings to use stimulants ▫ Stimulant use affects responsibilities

Chapter 104 Substance Use & Related Disorders ▫ Using stimulants despite social problems ▫ Giving up important activities for stimulants ▫ Using stimulants in dangerous situations ▫ Using stimulants even if they worsen a problem ▫ Becoming tolerant to stimulants ▫ Withdrawal symptoms ▪ Mild = 2–3 symptoms, moderate = 4–5 symptoms, severe ≥ six symptoms TREATMENT MEDICATIONS ▪ Modafinil (stimulates, reduces cravings) PSYCHOTHERAPY ▪ Motivational interviewing, peer-support programs Figure 104.6 An individual with a perforated nasal septum secondary to cocaine abuse. Cocaine causes vasoconstriction and ischemic necrosis. The hole has been closed with a translucent silicone button to provie structural support. Figure 104.5 Illustration showing the symptoms of cocaine withdrawal. OSMOSIS.ORG 753

Figure 104.7 Illustration showing some of the recommended approaches to immediate treatment of someone experiencing a cocaine overdose. OPIOID DEPENDENCE osms.it/opioid-dependence PATHOLOGY & CAUSES ▪ Inability to feel “normal” without opioid use ▪ Opioid use disorder: maladaptive pattern of opioid use ▪ Opioids = depressants ▪ Continued opioid use causes tolerance ▫ Opioid receptors become less sensitive, /neurons have fewer receptors (downregulation) ▫ Must use more to feel euphoric (positive reinforcement) ▪ Withdrawal COMPLICATIONS ▪ Disease transmission from shared needles, death by overdose (cardiac, respiratory depression) 754 OSMOSIS.ORG SIGNS & SYMPTOMS ▪ Increased opioid tolerance ▪ Upon withdrawal ▫ Anxiety, shivering, tremors, yawning, body aches, sweating, runny nose, abdominal cramps, diarrhea, vomiting, increased heart rate, blood pressure DIAGNOSIS OTHER DIAGNOSTICS ▪ ≥ two of following ▫ Consuming more opioids than intended ▫ Inability to cut down ▫ Opioid use takes up a lot of time ▫ Cravings to use opioids ▫ Opioid use affects responsibilities

Chapter 104 Substance Use & Related Disorders ▫ Using opioids despite social problems ▫ Giving up important activities for opioids ▫ Using opioids in dangerous situations ▫ Using opioids even if they worsen a problem ▫ Becoming tolerant to opioids ▫ Withdrawal symptoms ▪ Mild = 2–3 symptoms, moderate = 4–5 symptoms, severe = ≥ six symptoms TREATMENT MEDICATIONS ▪ Naloxone (blocks opioids), naltrexone, methadone (opioid for maintenance/ tapering consumption), buprenorphine PSYCHOTHERAPY ▪ Motivational interviewing, peer-support programs, cognitive behavioral therapy Figure 104.8 Illustration with examples of endogenous and exogenous opioids. Figure 104.9 Illustration showing the ways opioids are most commonly self-administered by people with opioid use disorder. OSMOSIS.ORG 755

TOBACCO DEPENDENCE osms.it/tobacco-dependence PATHOLOGY & CAUSES ▪ Inability to feel “normal” without tobacco use (nicotine) ▪ Tobacco use disorder: maladaptive pattern of tobacco use ▪ Tobacco = depressant, stimulant ▪ Continued tobacco use causes tolerance ▫ Nicotinic receptors become less sensitive/neurons have fewer receptors (downregulation) ▫ Must use more to feel euphoric (positive reinforcement) ▪ Withdrawal ▫ Using tobacco in dangerous situations ▫ Using tobacco even if it worsens a problem ▫ Becoming tolerant to tobacco ▫ Withdrawal symptoms ▪ Mild = 2–3 symptoms, moderate = 4–5 symptoms, severe = ≥ six symptoms COMPLICATIONS ▪ Heart attack, stroke, peripheral vascular disease, pulmonary disease, cancer (mouth, throat, lungs, bladder, pancreas, uterus) SIGNS & SYMPTOMS ▪ Increased tobacco tolerance ▪ Upon withdrawal ▫ Cravings, irritability, anxiety, anger, poor concentration, restlessness, impatience, increased appetite, weight gain, insomnia DIAGNOSIS Figure 104.10 An individual with tar stained fingers caused by tobacco smoking. OTHER DIAGNOSTICS ▪ ≥ two of following ▫ Consuming more tobacco than intended ▫ Inability to cut down ▫ Tobacco use takes up a lot of time ▫ Cravings to use tobacco ▫ Tobacco use affects responsibilities ▫ Using tobacco despite social problems ▫ Giving up important activities for tobacco 756 OSMOSIS.ORG TREATMENT MEDICATIONS ▪ Nicotine replacement therapies (gum, sprays, patches) to taper dose ▪ Bupropion (antidepressant; reduces cravings, withdrawal symptoms), varenicline (reduces cravings, enjoyment of tobacco)

Chapter 104 Substance Use & Related Disorders PSYCHOTHERAPY ▪ Motivational interviewing, peer-support programs OTHER INTERVENTIONS ▪ Switch to electronic cigarettes Figure 104.11 Illustration showing the effects of nicotine on the brain after binding to nicotinic receptors. Figure 104.12 Illustration showing the half-life of nicotine, which can lead to chain smoking. OSMOSIS.ORG 757

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