- Substance abuse: Pattern of using leading to significant impairment and ongoing use in spite of poor consequences (legal, professional, relationships)
- Substance dependence: Pattern of using leading to significant impairment or distress with drug tolerance, withdrawal, inability to cut down, and continued use despite problems
- Reward pathways are mediated by dopamine, GABA, and some peptides
- Stimulanant reward center: Ventral tegmentum, nucleus accumbens, frontal cortex
- Opiate reward center: Periaqueductal gray, arcuate nucleus, amygdala, locos coeruleus
- Genetics = 40-60% of vulnerability to addiction
- USPSTF says insufficient evidence to assess whether adolescents, adults, and pregnant women should be screened for drug use.
- Dilated pupils → stimulants and hallucinogens, withdrawal from opioids
- Constricted pupils → opioids
- Detox has 3 goals:
- begin abstinence,
- reduce withdrawal symptoms and complications,
- and keep the patient in treatment
- withdrawal is basically the flu = cramping, aches, anxiety, vomiting, malaise, goosebumps (cold turkey), runny nose, diarrhea, insomnia, elevated BP, and pulse
- Methadone – long-acting synthetic opioid. Can cause euphoria and sedation
- Buprenorphine – the partial agonist, lowers the risk of overdose, reduces/stops withdrawal symptoms. No euphoria and sedation.
- Naltrexone – long-acting synthetic opioid antagonist. Prevents feeling positive feelings from a drug, reduce withdrawal
- Naloxone – for acute intoxication treatment. Give nalOxOne at the Onset of Overdose
- Varenicline – partial agonist/antagonist. Minimal stimulation of opioid receptors but not enough for dopamine release → reduces cravings. Not studied in combination with other smoking cessation agents.
- Buproprion – blocks norepinephrine and dopamine reuptake
- Nicotine replacement
- – DTs in 48-72 hours. Naltrexone and acamprosate are most effective in combo with behavioral therapy.
- Naltrexone – reduces relapse by up to 36% in the first 3 months but not very good for the long term.
- Acamprosate – reduces withdrawal by acting on GABA and glutamate pathway. Good at maintaining abstinence in severe drinkers for several weeks to months
- Topiramate – like acamprosate but not FDA approved for this use
- Benzodiazepines (chlordiazepoxide, diazepam, lorazepam) – reduce the severity of withdrawal, reduce risk of seizures and DT
- Disulfiram – retention of acetaldehyde → flushing, nausea, vomiting
- Beta-blockers – as adjuncts to improve vital signs and reduce craving
- Clonidine – alpha agonists, decrease withdrawal severity
- paranoia, depression, sleepiness, anxiety, irritability, difficulty concentrating, increased appetite, motor retardation
- Propranolol – improves treatment retention, reduces cocaine use. Seems similar to the principle of naltrexone.
- Desipramine, buproprion – antidepressant
- Methylphenidate, amantadine – indirect dopamine agonists, improve treatment retention