Distinguished future physicians welcome to
Stomp on Step 1 the only free videos series
that helps you study more efficiently by focusing
on the highest yield material.
I’m Brian McDaniel and I will be your guide
on this journey through intoxication and withdrawal
seen with Substance abuse.
This is the 7th video in my playlist covering
all of psychiatry for the USMLE Step 1 medical
board exam.
We are going to review symptoms and treatments
for the use of various different drugs of
abuse.
This is low yield for the exam, but to just
give us a foundation we will start here.
Substance dependence is an adaption to a pattern
of substance use.
It is primarily characterized by withdrawal
(or symptoms that occur when use of the drug
is discontinued), tolerance (or needing more
to obtain the same desired effect), and spending
a significant portion of their time engaged
in drug related activities.
Substance abuse is an overindulgence in an
addictive substance as a result of a lack
of control.
It can be thought of as a more extreme version
of substance dependence in which individuals
have significant negative life effects with
work relationships or school), poor health,
or legal problems as a result of their substance
use.
In the general public this pattern of substance
abuse would more generally be referred to
as an addiction.
There is very specific DSM criteria for each
of these terms, but that isn’t important
for the exam.
For simplicity sake we will break the drugs
down into 3 different categories.
The 3 categories are Uppers, Downers and Hallucinogens.
There are slight differences between drugs
within individual categories, but for the
most part you can get questions right by just
knowing the general characteristics of the
entire group.
For example, you won’t see both cocaine
and MDMA listed as answers on the same question.
Also remember to not confuse intoxication
and withdrawal.
Most questions are on drug intoxication, but
they may specifically ask you about withdrawal
which usually has symptoms that are just the
opposite of intoxication.
So make sure you read the question carefully.
For example, the question stem may fit stimulant
withdrawal and depressant intoxication, but
the last sentence of the question specifically
asks about withdrawal.
Keep in mind the most important things for
Step 1 questions are the changes to the vitals
and pupils.
These should be the buzzwords you are looking
for.
You will almost always be given this information
in these types of questions and if you just
have that info you can usually narrow it down
to at least 2 options.
Also make sure you don’t get mydriasis vs.
miosis confused.
Mydriasis is the bigger word and has the bigger
pupils.
Miosis is the smaller word and has the smaller
pupils.
And obviously the best way to confirm a diagnosis
of drug use is a urine drug screen and mental
health services are important in the treatment
of addiction.
However, that is too easy so you won’t see
either of those as an answer on the exam so
I’m not going to spend much time on that.
That brings us to Uppers or stimulants….
Now I’ll try my hardest to not make 20 references
to Breaking Bad during this section, but I
can’t make any promises.
Most of the questions related to this category
will be about cocaine, which is usually smoked
in the form of crack cocaine or snorted.
However, other street drugs such as Methamphetamines
(Meth) & MDMA (Ecstasy & Molly) are also in
this group.
Prescription drugs used for ADHD, narcolepsy
and weight loss are also stimulants, but are
less likely to show up in this type of Step
1 question.
This group of drugs functions through a number
of different mechanisms, but primarily increases
dopamine and/or norepinephrine in the synaptic
cleft by inhibiting the reuptake of these
neurotransmitters.
Patients under the influence of these drugs
will have an acceleration of the nervous system.
This is going to be similar to a Sympathetic
fight or flight reaction.
You want your pupils dilated so you can see
the rhino that is trying to chase you down
and you want your blood pressure and respirations
higher so you can react to the threat.
Symptoms of stimulant use can include “increased
vitals” (tachycardia, hypertension, increased
temp and/or respirations), pupillary dilation,
irritability, anxiety, hyperactivity, diaphoresis
(sweating) & elevated mood.
Nasal septum ulceration or perforation and
nasal mucosal atrophy is a result of vasoconstriction
in individuals who snort cocaine.
This is another buzzword you should keep an
eye out for since it commonly shows up on
exams.
Accelerated tooth decay and tooth loss is
seen more commonly in users of meth and is
sometimes referred to as “Meth Mouth.”
Higher doses of these drugs result in overdose
which can lead to MI/Angina, seizure, hyperthermia,
stroke, arrhythmias, psychosis, rhabdomyolysis
or sudden death.
Treatment for an acute intoxication often
includes a combination of benzodiazepines,
antihypertensive and/or antipsychotics.
Withdrawal from Uppers usually doesn’t show
up on exams, but it presents with a “crash”
following drug cessation.
It is generally not life threatening, and
presents with fatigue, depression, irritability,
and psychomotor retardation.
Alcohol, opioids/opiates (such as heroin,
morphine, hydrocone, oxycodone), Sedative-hyponotics
(benzos & barbituates) fall into the category
of downers or depressants.
These drugs decrease neurotransmitters in
the nervous system and as you would expect
largely has a presentations that is the opposite
of uppers.
This class of drugs works through a number
of different mechanisms but mostly is due
to activation of inhibitory GABA and inhibition
of excitatory glutamate.
I’ve already created a video about alcohol
which covers alcohol metabolism and a number
of other topics such as the complications
of chronic alcoholism.
* To be taken to that video you can click
on this orange box here or you can look for
the link in the video description
I will be discussing benzodiazepines in much
more depth in the next video in the psychiatry
section which will cover all of psych pharm,
but I will also touch on the topic a little
here.
The use of downers can result in “depressed
vitals,” pupillary constriction (miosis),
↓ pain perception (hence why opioids are
pain medications), ↓ gastrointestinal motility
(abdominal pain & constipation), agitation,
decreased anxiety, and somnolence or sedation.
I don’t think I have to describe to you
want a drunk person looks like but for completeness
I’ll mention that use of downers and more
classically alcohol can present with disinhibition,
slurred speech, falls, incoordination, blackouts,
nausea & vomiting.
There are a couple laboratory tests that should
also make you consider alcoholism.
The two most important one are an elevation
in gamma-glutamyl transpeptidase (GGT) and
elevated liver enzymes (with an AST:ALT ration
≥ 2:1).
Heroin users may have identifiable needle
marks or track marks.
At higher doses an overdose can lead to loss
of consciousness and respiratory depression
(shallow or slow breaths).
This is why the most important intervention
for severe overdose of a downer is ventilatory
support.
For opioid overdose you often use an opioid
antagonist such as Naloxone (or Narcan), but
you also have to be careful with the dose
you give as you can easily cause withdrawal
by giving too much.
Flumazenil is a benzodiazepine receptor antagonist
that is sometimes used to treat benzo overdose.
Gastric lavage (AKA getting your stomach pumped)
and activated charcoal are rarely used in
overdoses.
Here is a slide from my earlier video on alcohol.
I just want to quick remind you that when
alcohol is consumed in large quantities Acetaldehyde,
an intermediate of alcohol metabolism, builds
up faster than it can be metabolized.
Acetaldehyde is one of the things that contributes
to hangover symptoms.
A hangover classically presents with nausea,
headache, fatigue, dizziness, gastrointestinal
problems, changes in mood & dehydration.
You can use a hangover to you advantage when
Disulfiram is used to treat alcoholism and
prevent relapse.
This drug Inhibits Acetaldehyde Dehydrogenase
and makes patients very sick if they drink
any alcohol as Acetaldehyde builds up much
faster.
You are essentially giving them a really bad
hangover on purpose to dissuade them from
drinking.
However, this it is not always effective as
there is relatively low compliance for this
drug.
Patients considering drinking can think ahead
and easily not take their medication to avoid
the consequences.
This is why Disulfiram is not commonly used,
but since it has basic science correlations
it still shows up in test questions.
More commonly counseling and mental health
interventions like a 12 step program are going
to be the treatment of choice for alcoholism
and opioid addiction.
Here is another slide from my earlier video
on alcohol.
It lists some of the more important complications
of alcoholism that are high yield for the
Step 1 exam.
I’m going to cover them in more depth in
videos in their respective organ system.
So for example esophageal pathology will be
covered in GI rather than here.
Most of the withdrawal questions you get will
be about the downers.
Withdrawal presents with symptoms that are
the opposite of intoxication.
So you will have elevated vitals, dilated
pupils, rhinorrhea (nasal discharge), diarrhea,
excessive perspiration, restlessness, insomnia,
anxiety, irritability & nausea/vomiting.
An odd presentation that should stick out
as a buzzword to you is yawning.
Opioid withdrawal is extremely uncomfortable,
but is not usually life threatening.
Benzodiazepine withdrawal and alcohol withdrawal
present very similarly and can be life threatening.
Prescription benzodiazepines, especially short
acting benzodiazepines, should be tapered
to prevent withdrawal.
Alcohol withdrawal has all of the withdrawal
symptoms we have discussed, but can also have
tremor, seizures, confusion, hallucinations
(mostly visual), delirium, coma and death.
The severe form of alcohol withdrawal is referred
to as Delirium Tremens or DTs.
The first line treatment for DTs is benzodiazepines.
You also have to monitor electrolytes (like
magnesium) and vitamins (like thiamine & folate).
Antipsychotics and/or temporary restraints
may be necessary for severe agitation.
Now we will move on to Hallucinogens.
PCP (Phencyclidine), LSD (Lysergic acid diethylamide)
and psychedelic mushrooms are in a category
of drugs called Hallucinogens.
As you might guess by the name the main feature
of this class is hallucinations and other
psychotic features.
This can be in the form of visual or tactile
hallucinations and may be tough to differentiate
from cocaine induced psychosis and other psychiatric
illnesses that are unrelated to substance
abuse.
I have already done an entire video on Psychosis.
If you would like to learn more about that
you can click on this orange box if you are
watching this video on a computer or if you
are watching on a phone you can go to find
the link in the video description.
Use of these drugs is not always accompanied
by hallucinations, but you are unlikely to
see a question on the exam that is missing
this classic presentation.
However, it may be useful to know that this
diverse group of substances can also cause
disorganized thoughts, paranoia, euphoria,
anxiety, labile mood, belligerence, incoordination
hyperthermia, and synesthesia (when letters
or numbers are perceived as color).
The effect on vitals and pupils varies with
dose and the specific agent being used.
PCP is associated with violence & aggression
more than any other drug.
PCP intoxication also classically presents
with Vertical or Horizontal Rotary Nystagmus
(or rhythmic eye motions).
Benzodiazepines and antipsychotics may be
used for treatment, but you can often just
monitor the patient for dangerous behavior.
These substances usually don’t present with
withdrawal symptoms.
Marijuana can cause conjunctival injection
(red eyes), increased appetite (AKA “the
munchies”), euphoria, perceptual changes,
mild tachycardia, anxiety, and dry mouth.
Marijuana may also be associated with schizophrenia
and transient psychosis which is why some
may put it in the hallucinogen category.
Users of marijuana usually do no present with
overdose or withdrawal symptoms.
No pharmacologic treatment is needed.
That brings us to the end of the video.
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