Psychotherapy: 118b - Substance Intoxication and Withdrawal

• Depression, dyspohria
  

  • High risk of suicidality

• Appetite stimulation, cravings

• Fatigue

• Sedation, slowing

• Irritability

• ANS hyperactivity

• Seizures

• Hallucinations

Key here is that the stages of withdrawal overlap

Every orifice is open and excreting things (kind of like cholinergic toxicity)

• Vomiting, diarrhea

• Sweating

• Tearing

• Pupil dilation

• Tremor, restlessness

• Anxiety/irritability

• Piloerection

• CB1
  

  • CNS effects: analgesia, psychoactive, GI

  • THC is a partial agonist

  • CBD is an antagonist

• CB2
  

  • Immune tissue

Usually generalized tonic-clonic

• Benzos or barbituates acutely
  

  • Phenytoin is less effective in alcohol withdrawal seizures

• Meiosis - very consistent finding w/opioid intoxication

• Euphoria, mood changes

• Respiratory depression

• Constipation, dry mouth, flushing

• Impaired reflexes

• Sativa = more THC
  

  • Energizing -> productive, creative

• Indica = more CBD
  

  • Relaxing, anxiolytic

Cocaine

Methamphetamine

Risk factors:

• Sustained alcohol use (chronic drinking)

• Prior history of delirium tremens

• Age 30+

• Concurrent medical illness

• Withdrawal begins while still intoxicated

Note: 95% of people who experience alcohol withdrawal DO NOT have delirium tremens

MDMA (aka molly, ecstacy)

• Downregulation of GABAa receptors
  

  • Alcohol stimulates GABAa receptors;
    constant stimulation -> downregulation

• Upregulation of NMDA receptors
  

  • Alcohol inhibits the NMDA receptor;
    constant block -> upregulation

3-5 days after last drink

May be 7-8 days for heavy drinkiers

95% of people who experience alcohol withdrawal WILL NOT have delirium tremens

• Euphoria

• Sense of connectedness

• Enhanced visual, tactile senses

• Extroversion

• Well-being

• Negative effects
  

  • Nausea, bruxism, motor restlessness

  • Serotonin syndrome possible

• Recurrent nausea and vomiting

• Dehydration

• Relief with hot showers

Usually happens when stopping after years of daily use

• More potent

• Longer acting

• Structurally different from THC
  

  • Not detected on urine drug screen

Not enough GABA signaling, excess glutamate signaling

NE and dopamine also play a role

• Alcohol stimulates GABAa receptors and inhibits glutamate receptors

• Withdrawal occurs when this is reversed, especially in chronic drinkers
  

  • Chronic alcohol GABAa activation -> downregulation

  • Chronic alcohol NMDA inhibition -> upregulation

• Mania

• Anxiety

• Restlessness

• High energy, low need for sleep

• Increased sympathetic tone

• Chest pain, arrhythmia

• Seizure

Dopamine, norepinephrine increase

• Anxiety, worry, restlessness

• Irritability, anger, aggression

• Sweating, fever, chills, tremor

• Abdominal pain, headache

• Insomnia

• Decreased appetite

• Dissociation
  

  • Depersonalization, derealization, psychosis

• Aggression

• Nystagmus - hallmark of PCP intoxication

• Autonomic symtoms

• Neuromuscular symptoms