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. If you are using my videos as one of your primary study aids and would like to help support the project please click on the green donate button here. Running the site takes a great deal of time, effort and money so anything you can spare would really help me out.
The next video in the psychiatry section is going to cover psych medications such as antidepressants, antipsychotics and mood stabilizers. If you would 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 buttons will work for you. But you should be able to find the donate button and the psych pharm video easily by going to the homepage of my website stomponstep1.com or by clicking the links in the video description Thank you so much for watching and good luck with the rest of your studying.
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