1. Martina Smit, MD Theresa Lo Sept 18, 2015
Addiction Psychiatry
Martina Smit, MD
Theresa Lo
Sept 18, 2015

2. Objectives Overview of addiction: Assessment
neurobiology
DSM5 criteria for substance use disorders
specific substance syndromes
Assessment
Substance use history
Treatment options, resources

3. Addiction: A primary, chronic disease of Brain reward Motivation
Memory, and related circuitry
American Society of Addiction Medicine

4. REWARD CIRCUITRY Associative learning 
High significance to substance,
Substance-rel’d cues
Marks salience of reward
Signals rewarding event
Will occur

5. 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):

6. Substance-related and addictive disorders
General diagnostic criteria
Substance-related and addictive disorders

7. DSM5 Substance Use disorder
2 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

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

9. Physiologic dependence
Tolerance
Withdrawal
need more for same effect;
or, less effect with same amount
characteristic syndrome;
Or, take same or similar substance to avoid it

10. Specific substance syndromes

11. Alcohol intoxication Slurred speech Dizziness Incoordination
Unsteady gait
Nystagmus
Impairment in attention or memory
Stupor or coma
- Many receptors involved

12. Alcohol: low risk use Men <65yo Women <65yo Special occasions:
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

13. 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
Tremulousness: 6-8 hours
Hallucinosis: 8-12 hours
Seizures: hours
DTS: anytime during the first 72 hours and can be within 1st week

14. 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
Inpatient: GI bleed, electrolyte abN, infxn, unstable CVD, pregnancy, SI, psychosis, significant cognitive impairment

15. Cannabis intoxication
Behavioral or psychological changes
Lower doses:
Relaxation, euphoria, altered time/sensory perception;
Higher doses:
Hypervigilance/paranoia; anxiety/panic; derealization/depersonalization; hallucinations
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)

16. 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

17. 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

18. Stimulant Withdrawal “Crashing” Dysphoria 2 or more of Fatigue
Vivid, unpleasant dreams
Insomnia or hypersomnia
Increased appetite
Psychomotor retardation or agitation

19. 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

20. Opioid withdrawal Anorexia Anxiety Craving Dysphoria Fatigue Headache
Burgeois J et al Eds 2012
Early to Moderate
Moderate to Advanced
Anorexia
Anxiety
Craving
Dysphoria
Fatigue
Headache
Irritabilityacrimation
Mydriasis (mild)
Perspiration
Piloerection “cold turkey”
Restlessness
Rhinorrhea
Yawning
Abdo cramps
Broken sleep
Hot/cold flashes
Incr BP
Low-grade fever
Muscle/bone pain
Muscle spasm “kick the habit”
Mydriasis
Nausea, vomiting

21. Sedative-Hypnotics Barbiturates Benzos Z-drugs (zopiclone)
Lethal in OD
Benzos
Bind to bzd receptors, enhance GABA
Z-drugs (zopiclone)
Intoxication and withdrawal similar to alcohol
Benzo intoxication: slurred speech, ataxia, altered LOC
Benzo withdrawal (can be life threatening): tremors, anxiety, perceptual disturbances, dysphoria, psychosis, seizures

22. Hallucinogens (LSD, others)
LSD interferes with serotonin neurotransporters
Psilocybin, mescaline, [mdma]
Intoxication (2 or more):
Pupillary dilation blurred vision
Tachycardia tremors
Sweating incoordination
palpitations
Behavioural / psychological changes: marked anxiety or depression, ideas of reference, fear of losing one’s mind, paranoid ideation, impaired judgement

23. 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
Behavioural changes: belligerence, assaultiveness, impulsiveness, unpredictability, psychomotor agitation, impaired judgement

24. 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
CNS depressant
Common: gasoline, glue, spray paint, solvents, cleaning fluids, other aerosols
Pharmacodynamics not well understood
Behaviour: apathy, diminished social and occupational functioning, impaired judgement, and impulsive or aggressive behaviour
Recent user: rashes around patient’s nose and mouth, unusual breath odours, residue on face, hands, clothing; irritation of eyes, throat, lungs, nose

25. 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?
Alcohol
Cannabis
Cocaine
Hallucinogens
Opioids Focus 2011

26. 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?
Alcohol
Cannabis
Cocaine
Heroin
Phencyclidine Focus 2011

27. Assessment

28. 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

29. 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

30. 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

31. Stages of change Prochaska & DiClemente 1992

32. Physical Exam

33. Meds
Treatment

34. Alcohol Naltrexone Acamprosate Disulfiram
Possibly (some evidence): topiramate, baclofen
Naltrexone: blocks opioid receptors -> reduced craving, reduced reward in response to drinking
Acamprosate: affects glutamate and GABA neurotransmitter systems (?EtOH effect)
Disulfuram: inhibits intermediate metabolism of alcohol
Topiramate: antagonizes glutamate, facilitates GABA
Baclofen: GABA agonist

35. Opioids Methadone Buprenorphine
Symtomatic trx (e.g. Clonidine, ibuprofen, tylenol, lorazepam, phenergan, imodium)
Clonidine: alpha 2 agonist with sympatholytic properties (net effect is to decrease NE)
Phenergan: for postnarcotic nausea

36. Nicotine
NRT (gum, patch, inhaler, spray)
Bupropion
Varenicline

37. 42yo F is started on a medication for alcohol dependence
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

38. Psychosocial
Treatment

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

40. Treatment settings Outpatient Day programs Residential
Recovery houses…

41. 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

42. 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