Addiction Psychiatric Medicine PDF
Preview Addiction Psychiatric Medicine
Addiction Psychiatric Medicine Addiction Psychiatric Medicine A COMPREHENSIVE BOARD REVIEW HÉCTOR A. COLÓN-RIVERA, MD, CMRO General, Addictions and Adolescent Psychiatrist, Faculty and Attending Physician, University of Pittsburgh Medical Center, Psychiatry Department, Pittsburgh, Pennsylvania Medical Director, APM, Philadelphia, Pennsylvania ELIE G. AOUN, MD, MRO, FAPA General, Addictions and Forensic Psychiatrist, Assistant Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons - Division of Law, Ethics, and Psychiatry, New York, New York LEILA M. VAEZAZIZI, MD Clinical Instructor and Addiction Psychiatrist, Montefiore Medical Center/Albert Einstein College of Medicine, New York, New York Faculty, New York University School of Medicine, New York, New York CONTENTS 1 GENERAL PRINCIPLES OF SUBSTANCE USE 11 ASPECTS OF PAIN ...................................99 DISORDERS ................................................1 12 DRUG TESTING, FORENSIC 2 COMORBIDITIES OF SUBSTANCE USE ADDICTIONS, AND ETHICS ..................103 DISORDERS ..............................................11 13 PSYCHOSOCIAL APPROACHES 3 NEUROBIOLOGY OF ADDICTION .............19 TO SUBSTANCE USE DISORDER MANAGEMENT .....................................109 4 ALCOHOL USE DISORDER .......................31 14 PRACTICE TESTS ...................................119 5 SEDATIVES AND HYPNOTICS ...................47 REVIEW QUESTIONS ANSWER KEY 6 OPIOID USE DISORDER............................57 (CHAPTERS 1–13)........................................145 7 TOBACCO AND OTHER NICOTINE PRACTICE TESTS ANSWER KEY PRODUCTS ...............................................67 (CHAPTER 14) .............................................161 8 CANNABIS USE DISORDER .......................73 INDEX .........................................................189 9 STIMULANTS USE DISORDER ...................85 10 DISSOCIATIVE DRUGS, HALLUCINOGENS, CAFFEINE, INHALANTS, AND OTHER SUBSTANCES OF ABUSE .........................91 v Elsevier 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 ADDICTION PSYCHIATRIC MEDICINE: A COMPREHENSIVE ISBN: 978-0-323-75486-6 BOARD REVIEW Copyright © 2023 by Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Senior Content Strategist: Melanie Tucker Content Development Specialist: Laura Fisher Senior Content Development Manager: Laura Schmidt Publishing Services Manager: Deepthi Unni Senior Project Manager: Manchu Mohan Senior Book Designer: Margaret Reid Printed in India. Last digit is the print number: 9 8 7 6 5 4 3 2 1 1 GENERAL PRINCIPLES OF SUBSTANCE USE DISORDERS DEFINITIONS OF SUBSTANCE USE 8.Continued use despite recurrent social or DISORDERS AND DIAGNOSTIC interpersonal problems EVALUATIONS 9.Use resulting in important social, occupational, or recreational activities given Although persons with a substance use disorder (SUD) up or reduced use drugs or alcohol, using these substances does not Physiological Dependence necessarily mean that a given person meets SUD diag- 10.Tolerance nostic criteria. Indeed, in 2012, the American Psychi- 11.Withdrawal atric Association’s Diagnostic and Statistical Manual, 5th Edition (DSM-5) set diagnostic phenomenological Note that for individuals developing tolerance or parameters for SUD diagnoses. These replace older withdrawal to a medically prescribed substance, tol- diagnoses of substance abuse and substance depen- erance and withdrawal do not count in diagnosing dence from the DSM’s previous editions. a SUD. DSM-5 definition of SUD: A maladaptive substance SUD severity is assessed by the number of diag- use pattern leading to significant impairment or dis- nostic criteria (2–3: mild; 4–5: moderate; 6 or more: tress. This definition is met when a person meets at severe), not by the severity of substance use or the least two of the following 11 diagnostic criteria within severity of any individual criteria. a 12-month period: A SUD diagnosis can be further qualified as: Loss of Control 1. Substance taken in larger amount or for a ■ Early remission: When a person who previously longer period than intended met diagnostic criteria for SUD has not met any 2. Persistent desire or unsuccessful efforts to diagnostic criteria (except for craving) for longer control or stop substance use than three months. 3. Craving or a strong desire or urge to use the ■ Sustained remission: When a person who previ- substance ously met SUD, diagnostic criteria has not met 4. Use continues despite knowledge of resultant any diagnostic criteria (except for craving) for physical or psychological problems longer than 12 months. 5. Continued use in situations in which it is ■ On maintenance therapy: When a person who physically hazardous previously met diagnostic criteria for SUD has not met any diagnostic criteria (except for tol- Adverse Consequences erance or withdrawal) as a result of being pre- 6. Great deal of time spent to obtain, use, or scribed maintenance medications (referring to recover from effects full or partial agonists and antagonist medica- 7. Use resulting in a failure to fulfill major role tions such as naltrexone, buprenorphine, or obligations methadone). 11 2 ADDICTION PSYCHIATRIC MEDICINE: A COMPREHENSIVE BOARD REVIEW ■ In a controlled environment: When a person who tolerance described earlier. Conditioned tol- previously met diagnostic criteria for SUD is absti- erance refers to the presence of conditioned nent as a result of no longer having access to the compensatory responses in response to using substance when in an environment where access a substance in a novel environment, rather to the substance is restricted (such as correctional than their familiar place of use. Conditioned detention or residential rehabilitation programs). tolerance can be seen for example when a per- son with opioid use disorder experiences an Physiological dependence refers to the state result- opioid overdose when they use heroin in a new ing from repeated use of a substance marked by toler- environment. ance and/or withdrawal symptoms: 3. Incentive salience refers to yet another phenom- ■ Tolerance to a given substance is a phenom- enon. With incentive salience, specific environ- enon marked by requiring a higher dose of mental sensory or experiential cues become as- the substance to achieve the same intoxicating sociated with using a given substance (such as effect (alternatively, it can be conceptualized as smells, places of use, or persons with whom one experiencing a reduced effect if the individual uses). This leads to a physical state of expecta- consumed their usual dose). tion of substance use when encountering these ■ Withdrawal is a syndrome occurring following dis- cues. For example, someone using cocaine at a continuation or reduction of substance use marked nightclub will experience a strong urge to use co- by symptoms opposite to the expected effects of caine again every time they go to the nightclub. that substance. Resuming substance use would 4. Incentive salience is driven by operant condi- reverse the withdrawal and relieve these symptoms. tioning (conditioning using positive or nega- tive reinforcement) or classical conditioning The 4 C’s is another commonly used working descr- (Pavlovian conditioning). iption of the components of SUD. Working Definitions of Addiction: ■ Compulsion SUD SEVERITY AND PATIENT ■ Loss of Control PLACEMENT CRITERIA ■ Consequences ■ Craving The American Society of Addiction Medicine (ASAM) patient placement criteria (PPC-2R) offer a standard- Know This: ized approach to connect a person’s SUD severity and characteristics with the treatment level they require. 1. Rebound symptoms and pseudo-withdrawal Using the PPC-2R, persons with SUD are assessed for are two phenomena that are distinct from sub- their treatment needs in six dimensions (each scored stance withdrawal. Rebound symptoms refer 0–4 based on the associated complication risks): to situations in which symptoms preceding the drug use affected by the use worsen after ■ Dimension 1: Intoxication and withdrawal pote- discontinuation (e.g., persons with insomnia ntial using benzodiazepines to sleep might experi- ■ Dimension 2: Biomedical conditions and com- ence worsening insomnia after benzodiaz- plications epines discontinuation). Pseudo-withdrawal ■ Dimension 3: Emotional, behavioral, or cogni- refers to placebo-type symptoms experienced tive complications when a person using a substance considers or ■ Dimension 4: Readiness to change (trans-theo- expects the substance’s discontinuation. These retical model of change or stages of change) symptoms resemble symptoms that would like- ■ Dimension 5: Relapse or continued use potential ly occur with drug discontinuation. ■ Dimension 6: Recovery environment (including 2. Conditioned (or learned) tolerance refers to a social, legal, vocational, educational, financial, different phenomenon than the physiological and housing factors) 1 GENERAl PRINCIPlES OF SuBSTANCE uSE DISORDERS 3 Treatment type needs for every dimension are 2. Do not confuse placement matching and mo- determined and classified by level: dality matching. “Placement matching” refers to the required intensity of treatment resources ■ Level 0? as identified in the PPC-2R, whereas “modal- ■ Level 0.5: Early intervention ity matching” refers to whichever clinical ap- ■ Level I: Outpatient treatment proach might be optimal in treating a patient’s ■ Level II.1: Intensive outpatient problems (such as using contingency manage- ■ Level II.5: Partial hospitalization ment for stimulant use disorders, buprenor- ■ Level III.1: Clinically managed low-intensity res- phine for opioid use disorder, or dialectical idential services behavioral therapy [DBT] for borderline per- ■ Level III.3: Clinically managed medium-inten- sonality disorder). sity residential treatment Child and adolescent levels of care utilization ser- ■ Level III.5: Clinically managed high-intensity vices (CAlOCuS) is a model similar to PPC-2R that residential treatment is specific for identifying necessary levels of care for ■ Level III.7: Medically monitored intensive inpa- adolescent SuD. Basic services or prevention repre- tient treatment sent the least restrictive level of care in the CAlOCuS ■ Level IV: Medically managed intensive inpatient model (level 0), whereas a secure 24-hour medical treatment management program is the most restrictive level When applicable, subspecifiers are used to denote (level 6). treatment types further: ■ D: Detoxification STATISTICS AND EPIDEMIOLOGICAL ■ OMT: Opioid maintenance treatment ■ BIO: Capable of managing complex medical TIDBITS comorbidity It is not uncommon for the boards to ask a couple of ■ AOD: Alcohol or drug treatment only basic statistical questions, most commonly addressing ■ DDC: Dual diagnosis capable (the treatment facility sensitivity, specificity, positive and negative predictive can identify co-occurring psychiatric problems and values, or the types of biases in scientific research. refer to outside mental health treatment centers) Test positive Test negative ■ DDE: Dual diagnosis enhanced, capable on-site Condition True positive False negative of managing patients with co-occurring psychi- present (TP) (FN) atric problems Condition False positive True negative The PPC-2R model is presented as a matrix grid in absent (FP) (TN) which illness dimensions are listed on the Y-axis and Sensitivity and specificity present the means to assess treatment types on the X-axis. how accurate a diagnostic test demonstrates the pres- For example, a patient with alcohol use disorder ence or absence of a condition. They address the likeli- and depression seeking treatment might require initial hood of a given test outcome for persons who have or do care in a Level IV-D (inpatient detoxification) followed not have the condition. A test with high specificity will by a II.5-DDE (partial hospital program that is dual help Rule-In the condition (Specificity – IN → SPIN), diagnosis enhanced) whereas a high sensitivity test will help Rule-Out the Know This: condition (Sensitivity – OUT → SNOUT). For example, gamma-glutamyl transferase is a highly specific but not 1. The role of coercion in treatment or the impact very sensitive biomarker of alcohol use disorder. of one’s experienced adverse consequences of In contrast, positive predictive value (PPV) and substance use affects their motivation for treat- negative predictive value (NPV) address the likelihood ment and is assessed in Dimension 4 (readiness of having a condition for persons who test positive to change). or negative. As such, a test with high PPV will have a
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