alcohol withdrawal treatment

distinguished future physicians welcome tostomp on step 1 the only free videos series that helps you study more efficiently by focusingon the highest yield material. i’m brian mcdaniel and i will be your guide on thisjourney through intoxication and withdrawal seen with substance abuse. this is the 7thvideo in my playlist covering all of psychiatry for the usmle step 1 medical board exam. weare going to review symptoms and treatments for the use of various different drugs ofabuse. this is low yield for the exam, but to justgive us a foundation we will start here. substance dependence is an adaption to a patternof substance use. it is primarily characterized by withdrawal (or symptoms that occur whenuse of the drug is discontinued), tolerance

(or needing more to obtain the same desiredeffect), 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 lackof control. it can be thought of as a more extreme version of substance dependence inwhich 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 publicthis 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 importantfor the exam. for simplicity sake we will break the drugsdown into 3 different categories. the 3 categories

are uppers, downers and hallucinogens. thereare slight differences between drugs within individual categories, but for the most partyou can get questions right by just knowing the general characteristics of the entiregroup. for example, you won’t see both cocaine and mdma listed as answers on the same question. also remember to not confuse intoxicationand withdrawal. most questions are on drug intoxication, but they may specifically askyou 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 stimulantwithdrawal and depressant intoxication, but the last sentence of the question specificallyasks about withdrawal.

keep in mind the most important things forstep 1 questions are the changes to the vitals and pupils. these should be the buzzwordsyou are looking for. you will almost always be given this information in these types ofquestions 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 smallerword and has the smaller pupils. and obviously the best way to confirm a diagnosisof drug use is a urine drug screen and mental health services are important in the treatmentof addiction. however, that is too easy so you won’t see either of those as an answeron 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 ican’t make any promises. most of the questions related to this categorywill 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 inthis 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 numberof different mechanisms, but primarily increases

dopamine and/or norepinephrine in the synapticcleft by inhibiting the reuptake of these neurotransmitters. patients under the influence of these drugswill have an acceleration of the nervous system. this is going to be similar to a sympatheticfight or flight reaction. you want your pupils dilated so you can see the rhino that is tryingto chase you down and you want your blood pressure and respirations higher so you canreact to the threat. symptoms of stimulant use can include “increasedvitals” (tachycardia, hypertension, increased temp and/or respirations), pupillary dilation,irritability, anxiety, hyperactivity, diaphoresis (sweating) & elevated mood.

nasal septum ulceration or perforation andnasal mucosal atrophy is a result of vasoconstriction in individuals who snort cocaine. this isanother buzzword you should keep an eye out for since it commonly shows up on exams. acceleratedtooth decay and tooth loss is seen more commonly in users of meth and is sometimes referredto as “meth mouth.” higher doses of these drugs result in overdosewhich can lead to mi/angina, seizure, hyperthermia, stroke, arrhythmias, psychosis, rhabdomyolysisor sudden death. treatment for an acute intoxication oftenincludes a combination of benzodiazepines, antihypertensive and/or antipsychotics. withdrawalfrom uppers usually doesn’t show up on exams, but it presents with a “crash” followingdrug 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 categoryof downers or depressants. these drugs decrease neurotransmitters in the nervous system andas you would expect largely has a presentations that is the opposite of uppers. this classof drugs works through a number of different mechanisms but mostly is due to activationof inhibitory gaba and inhibition of excitatory glutamate.i’ve already created a video about alcohol which covers alcohol metabolism and a numberof other topics such as the complications of chronic alcoholism. * to be taken to thatvideo you can click on this orange box here

or you can look for the link in the videodescription i will be discussing benzodiazepines in muchmore 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 “depressedvitals,” pupillary constriction (miosis), ↓ pain perception (hence why opioids arepain medications), ↓ gastrointestinal motility (abdominal pain & constipation), agitation,decreased anxiety, and somnolence or sedation. i don’t think i have to describe to youwant a drunk person looks like but for completeness i’ll mention that use of downers and moreclassically alcohol can present with disinhibition,

slurred speech, falls, incoordination, blackouts,nausea & vomiting. there are a couple laboratory tests that shouldalso make you consider alcoholism. the two most important one are an elevation in gamma-glutamyltranspeptidase (ggt) and elevated liver enzymes (with an ast:alt ration ≥ 2:1). heroin usersmay have identifiable needle marks or track marks. at higher doses an overdose can lead to lossof consciousness and respiratory depression (shallow or slow breaths). this is why themost 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), butyou also have to be careful with the dose

you give as you can easily cause withdrawalby giving too much. flumazenil is a benzodiazepine receptor antagonist that is sometimes usedto 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. acetaldehydeis one of the things that contributes to hangover symptoms. a hangover classically presentswith nausea, headache, fatigue, dizziness, gastrointestinal problems, changes in mood& dehydration.

you can use a hangover to you advantage whendisulfiram is used to treat alcoholism and prevent relapse. this drug inhibits acetaldehydedehydrogenase and makes patients very sick if they drink any alcohol as acetaldehydebuilds up much faster. you are essentially giving them a really bad hangover on purposeto dissuade them from drinking. however, this it is not always effective as there is relativelylow compliance for this drug. patients considering drinking can think ahead and easily not taketheir 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 goingto be the treatment of choice for alcoholism

and opioid addiction. here is another slide from my earlier videoon alcohol. it lists some of the more important complications of alcoholism that are highyield for the step 1 exam. i’m going to cover them in more depth in videos in theirrespective organ system. so for example esophageal pathology will be covered in gi rather thanhere. most of the withdrawal questions you get willbe 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 outas a buzzword to you is yawning. opioid withdrawal is extremely uncomfortable,but is not usually life threatening. benzodiazepine withdrawal and alcohol withdrawal presentvery similarly and can be life threatening. prescription benzodiazepines, especially shortacting benzodiazepines, should be tapered to prevent withdrawal. alcohol withdrawal has all of the withdrawalsymptoms we have discussed, but can also have tremor, seizures, confusion, hallucinations(mostly visual), delirium, coma and death. the severe form of alcohol withdrawal is referredto 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 categoryof drugs called hallucinogens. as you might guess by the name the main featureof this class is hallucinations and other psychotic features. this can be in the formof visual or tactile hallucinations and may be tough to differentiate from cocaine inducedpsychosis 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 arewatching this video on a computer or if you are watching on a phone you can go to findthe link in the video description. use of these drugs is not always accompaniedby hallucinations, but you are unlikely to see a question on the exam that is missingthis classic presentation. however, it may be useful to know that this diverse groupof substances can also cause disorganized thoughts, paranoia, euphoria, anxiety, labilemood, belligerence, incoordination hyperthermia, and synesthesia (when letters or numbers areperceived as color). the effect on vitals and pupils varies withdose and the specific agent being used. pcp is associated with violence & aggressionmore than any other drug. pcp intoxication

also classically presents with vertical orhorizontal rotary nystagmus (or rhythmic eye motions).benzodiazepines and antipsychotics may be used for treatment, but you can often justmonitor the patient for dangerous behavior. these substances usually don’t present withwithdrawal 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 schizophreniaand transient psychosis which is why some may put it in the hallucinogen category. usersof marijuana usually do no present with overdose or withdrawal symptoms. no pharmacologic treatmentis needed.

that brings us to the end of the video. ifyou are using my videos as one of your primary study aids and would like to help supportthe project please click on the green donate button here. running the site takes a greatdeal of time, effort and money so anything you can spare would really help me out. the next video in the psychiatry section isgoing to cover psych medications such as antidepressants, antipsychotics and mood stabilizers. if youwould like to be taken directly to that video you can click on this black box here.unfortunately, if you are watching this video on a phone or tablet neither of these buttonswill work for you. but you should be able to find the donate button and the psych pharmvideo easily by going to the homepage of my

website stomponstep1.com or by clicking thelinks in the video description thank you so much for watching and good luckwith the rest of your studying