Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5538_Библиотеки_им_академика_М_И_Перельмана
.pdf
246 Substance Use in Older Adults
mains unsure about stopping methamphetamine use but does agree to
follow up with outpatient mental health, as he found the olanzapine
helpful in helping him “to stay more calm.”
Long-term use of methamphetamine is associated with severe tooth
and gum decay; loss of teeth gives a distinctive appearance known as
“meth mouth.” This phenomenon is from long periods of poor dental
hygiene, methamphetamines being acidic, and methamphetamineinduced physiological changes that are damaging to teeth such as bruxism and reduced salivary production with lower pH (Rommel et al.
2016a, 2016b). Poor dentition affects nutritional status, a common concern in older patients, and meth mouth further compounds dentition
problems in older adults.
Stimulant withdrawal is not life-threatening; hallmarks are sedation,
dysphoria, excessive
continuation in early-phase withdrawal results in apathy, anhedonia,
anxiety
, confusion, intense drug cravings, depression, increased appetite,
hypersomnia, and vivid, unpleasant dreams (Pagliaro and Pagliaro
2022). This withdrawal phase resolves within about a week. Early-phase
withdrawal is where most users perpetrate violence. Later-phase withdrawal results in less severe signs for ≤2 weeks (McGregor et al. 2005).
hunger and craving, and depression. Abrupt dis-
Cocaine
The route of administration (intravenous, inhaled, oromucosal, intranasal, rectal, or vaginal) affects cocaine’s onset of action. Cocaine that is
oked or injected has a more rapid onset (~1 minute to peak blood
sm
concentration) than when consumed orally (chewing coca leaves) (~45
minutes) or intranasally (~10 minutes); effects last 15 minutes, 1–3
hours, and ≤90 minutes, respectively (Drake and Scott 2018).
During acute cocaine intoxication, reuptake of dopamine and
serotonin is decreased in the central nervous system (CNS), and users
experience physical symptoms of tachycardia, diaphoresis, bruxism,
headache lasting several hours to days, nausea, tremor, and appetite
suppression; behavioral symptoms of restlessness, agitation, and tactile
hallucinations; and psychiatric symptoms of emotional lability, euphoria, grandiosity, anxiety, paranoia, and dysphoric mood (Dackis and
Gold 1990). As use continues, CNS stimulation increases with resulting
dyspnea, hypertension, hyperthermia, pressured speech, seizures,
tachypnea, and vomiting. Acute use is associated with vasoconstriction
(Lange et al. 1989), and coronary vasospasm can cause myocardial infarction (Hollander et al. 1994). Cocaine can also cause heart failure, cardiomyopathy,
aortic dissection, stroke, and arrhythmias (Havakuk et al.
Stimulant Use Disorder in Older Adults 247
2017). Vasoconstriction can prevent heat from dissipating, and hyperthermia can result in psychomotor agitation. Mortality can reach 33% in
cases of cocaine-induced hyperthermia (Marzuk et al. 1998). Smoking
cocaine can cause acute pulmonary toxicity or “crack lung,” which refers to diffuse hemorrhagic alveolitis that occurs within 48 hours of
smoking crack cocaine (Forrester et al. 1990).
Endogenous neurotransmitters are ultimately depleted as use continues and depression of CNS occurs, and users enter withdrawal. Possible effects include fatigue, difficulty concentrating, increased appetite,
intense cocaine craving, hypersomnia, distu
rbing dreams, areflexia,
cardiac arrest, circulatory failure, respiratory failure, and flaccid paralysis. Physical symptoms of withdrawal are usually minor, however,
and include tremors, chills, bradycardia, involuntary muscle movement, and nonspecific musculoskeletal pain (Viola et al. 2014). The psychiatric symptom of this period is referred to as the “cocaine blues” and
is marked by depression and anxiety with possible suicidal ideation.
This phase resolves when the depleted neurotransmitters have had sufficient time to replenish, usually within 1–2 weeks. The first week of
withdrawal has also been associated with myocardial ischemia due to
coronary vasospasm (Nademanee et al. 1989). We present a case of an
older adult with depression and suicidal ideation during cocaine withdrawal in Case Example 9–2.
Case Example 9–2: “I feel terrible all of the
time”
Mr. Mahdavi is a 73-year-old man who presents to the hospital with failure to thrive in the setting of continuous cocaine use. Mr. Mahdavi’s cocaine use increased roughly 3 months previously when he lost his longterm housing after failure to pay rent. He has been staying in shelters
since that t
falls, and loss of bowel and bladder continence. On initial evaluation, he
is disengaged and hypersomnolent, but when awake, hyperphagic.
Medical workup is nonrevealing aside from electrolyte disturbance that
resolves with supportive care. On the third day of hospitalization, he tells
a nurse that he would rather be dead than continue living like he is, so
the psychiatry consultation team is asked to evaluate the patient for suicidal ideation.
died 4 months earlier of a myocardial infarction after they had been
using cocaine in their normal binge fashion, roughly once a month for
24–36 hours continuously. Shortly after the roommate’s death, Mr. Mahdavi’s cocaine use increased, and he could no longer pay rent and was
evicted. He reported continuous use of cocaine, which he smokes multiple times per day. When he is not smoking, he feels depressed, over-
ime and has had a 20-pound unintended weight loss, multiple
On exam, Mr. Mahdavi reports that his roommate of 15 years had
248 Substance Use in Older Adults
whelmed, and tired. He gets intense suicidal thoughts that peak a day
or two after stopping cocaine and abate when he uses again. He has
never experienced suicidal ideation before. He has no history of major
depression and, before his roommate’s death, he was in his usual state
of health, though he admittedly was not tending to his underlying hypertension. After psychiatric evaluation and engagement, the patient is
clear he wants to live but struggles with intense dysphoria and suicidal
ideation while coming down from cocaine. He receives supportive care
and, after motivational interviewing, is transferred to a skilled nursing
facility for physical rehabilitation with a plan to follow up with residential treatment for cocaine use disorder.
Long-term cocaine use has been associated with depression, paranoia, decreased libido, male impotence, psychosis, cognitive impairment (Pagliaro and Pagliaro 2022), increased risk of seizures and stroke
(Brust 2014;
Koppel et al. 1996), antipsychotic-associated dystonic reactions, and exacerbation of tardive dyskinesia and Tourette syndrome
(Asser and Taba 2015; van Harten et al. 1998). Cocaine psychosis has a
presentation similar to that of methamphetamine psychosis and appears like schizophrenia, but of shorter duration. Clinicians should
monitor patients for suicidal ideation, especially in the acute phase, as
cocaine is associated with an increased rate of past-year suicide attempts relative to other substances (Armoon et al. 2021). Chronic cocaine use can result in excoriation and prurigo due to scratching from
e parasitosis (Lipman and Yosipovitch 2021). Long-term cocaine
tactil
use is associated with cardiac and (if smoked) pulmonary dysfunction
and increased incidence of perforated gastric ulcers and gastrointestinal
ischemia (Butler et al. 2017; Cregler 1991; Haim et al. 1995).
Other Issues
Levamisole, an anthelmintic drug used in veterinary medicine to treat
parasitic infections, is a common adulterant in cocaine that causes
agranulocytosis and vasculitis. Users of levamisole-adulterated cocaine
can develop painful cutaneous papules and necrosis. The face, ears, and
cheeks are commonly involved, but any part of the skin can be affected.
Over the past two decades, opioids—particularly fentanyl (a synthetic potent opioid)—have been increasingly found as an adulterant in
both cocaine and methamphetamine supplies and are contributing to fatal overdoses. Opioids cause death through respiratory depression, and
this risk i
do not also misuse opioids. An increase in cocaine deaths since 2006 has
been driven by opioids, particularly synthetic opioids, although both fatal and nonfatal overdoses are occurring without opioids (Hoots et al.
s increased in opioid-naive users, such as stimulant users who
Stimulant Use Disorder in Older Adults 249
2020). Urine drug tests from health care settings in the United States
show that the rate of illicit fentanyl co-occurring with cocaine increased
from 0.9% in 2013 to 17.6% in 2018, and that co-occurring with methamphetamines increased from 0.9% to 7.9% (LaRue et al. 2019).
Stimulant use at low doses can enhance arousal cognition, but moderate to high doses lead to cognitive impairment and dysfunction.
Acute and long-term stimulant misuse can cause cognitive deficits in
executive function, such as task-shifting and impulsivity, and temporal
lobe deficits, such as working memory and verbal memory (Ornstein et
al. 2000; Verdejo-Garcia and Rubenis 2020). Among older adults, stimulant misuse may exaggerate existing cognitive deficits. Methamphetamine misuse can increase the risk of dementia, including Alzheimer
e and vascular dementia (Tzeng et al. 2020).
diseas
We present a comparison of methamphetamines and cocaine in
Table 9–2.
SCREENING AND ASSESSMENT
• Clinicians should consider using instruments that screen for illicit
substances (which are not specific to stimulants). Examples include
the one-question screen, “How many times in the past year have you
used an illegal drug or used a prescription medication for nonmedical reasons?”, adapted from the 10-item Drug Abuse Screening Test
(DAST-10) (Smith et al. 2010); Screen of Drug Use (Tiet et al. 2015);
and the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool (McNeely et al. 2016).
Although these tools are designed for self-report or clinician interview, a reliable informant can theoretically complete the screening tool
if a pati
might be preferable to no screening at all. Ultimately, a diagnosis of
stimulant use disorder is made using DSM-5-TR criteria (Box 9–1).
ent with cognitive impairment cannot reliably self-report. This
Box 9–1. Stimulant Use Disorder
Diagnostic Criteria
A. A pattern of amphetamine-type substance, cocaine, or other stimulant
use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
250 Substance Use in Older Adults
Table 9–2. Comparison of methamphetamines and cocaine
Category Methamphetamines Cocaine
Classification Psychostimulant, synthetic Psychostimulant, natural
Available forms Powdered crystal Cocaine base (crack,
rock
s); cocaine HCl
(powdered crystal)
Desired effects Long-lasting euphoria Brief euphoria
Medical uses ADHD (brand name
Desoxyn)
Methods of use Ingested, dissolved,
intravenously injected,
snorted, or heated and the
fumes inhaled
Mechanism of
action
Metabolism/
eliminati
Street names Crank, crystal, glass, ice,
Source. Adapted from Pagliaro and Pagliaro 2022.
on
Increases dopamine release
and blocks reuptake
Urine; 12-hour half-life Urine; 1-hour half-life
meth, spee
d, Tina, tweak
Limited use as a local
anesthetic for brief
surgical or dental
procedures
Cocaine HCl—snorted or
dissolved and
intravenously injected;
cocaine base—heated
and fumes are inhaled
Blocks dopamine reuptake
Cocaine HCl—blow, C,
coke, nose candy,
powder, snow, toot;
cocaine base—crack,
freebase, rock
1. The stimulant is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or
control stimulant use.
3. A great d
stimulant, use the stimulant, or recover from its ef
eal of time is spent in activities necessary to obtain the
fects.
4. Craving, or a strong desire or urge to use the stimulant.
5. Recurrent stimulant use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued stimulant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects
of the stimulant.
7. Important social, occupational, or recreational activities are given
up or reduced because o
f stimulant use.
8. Recurrent stimulant use in situations in which it is physically hazardous.
Stimulant Use Disorder in Older Adults 251
9. Stimulant use is continued despite knowledge of having a persistent
or recurrent physical or psychological problem that is likely to have
been caused or exacerbated by the stimulant.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of the stimulant to
achieve intoxic
ation or desired effect.
b. A markedly diminished effect with continued use of the same
amount of the st
imulant.
Note: This criterion is not considered to be met for those taking
stimulant medi
cations solely under appropriate medical supervision, such as medications for attention-deficit/hyperactivity disorder or narcolepsy.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for the stimulant (refer
to Criteria A and B of the criteria set fo
r stimulant withdrawal).
b. The stimulant (or a closely related substance) is taken to relieve
or avoid withdr
awal symptoms.
Note: This criterion is not considered to be met for those taking
stimulant medi
cations solely under appropriate medical supervision, such as medications for attention-deficit/hyperactivity disorder or narcolepsy.
Specify if:
In early remission: After full criteria for stimulant use disorder were
previously met, none of the criteria
for stimulant use disorder have been
met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the
stimulant,” may be met).
In sustained remission: After full criteria for stimulant use disorder
were previously met, none of the criteria for stimulant use disorder have
been met at any time during a period of 12 months or longer (with the
exception that Criterion A4, “Craving, or a strong desire or urge to use
the stimulant,” may be met).
Specify if:
In a controlled environment: This additional specifier is used if the in-
dividual is in an environment where access to stimulants is restricted.
Specify current severity:
Mild: Presence of 2–3 symptoms.
Moderate: Presence of 4–5 symptoms.
Severe: Presence of 6 or more symptoms.
Source. Reprinted from American Psychiatric Association: Diagnostic and Statistical Man-
ual of Mental Disorders, 5th Edition, Text Revision. Washington, DC, American Psychiatric
sociation, 2022. Copyright © 2022 American Psychiatric Association. Used with per-
As
mission.
252 Substance Use in Older Adults
A clinical assessment and urine drug screen (UDS) is usually sufficient to make a clinical diagnosis of stimulant use disorder. In the initial
asses
sment, clinicians should focus on the route of use, amount, time
since last use, and medical and psychiatric comorbidities. To differentiate between stimulant use and an underlying psychiatric disorder, clinicians should collect collateral information from reliable sources such
as family, close frien
form a full clinical assessment.
Benzoylecgonine, a cocaine urinary metabolite, can be positive on a
or ≤ 3 days after last use in sporadic users and ≤ 10 days in heavy
UDS f
users (American
is highly specific for benzoylecgonine, and false positives are uncommon. Therefore, if a patient has a UDS positive for cocaine and collateral
information supports the clinical impression of cocaine use disorder,
clinicians can be fairly confident in the diagnosis.
Unlike cocaine, amphetamines (including methamphetamine) produce many false-positive results on UDS (Table 9–3), because they exist
as two enantiomers.
tests are used to identify the ratio of enantiomers (Brahm et al. 2010).
Methamphetamine metabolites can be positive on a UDS for 3–5 days
since last use and up to a week in heavy users. Providers should not
withhold acute care for suspected methamphetamine intoxication to
await confirmatory toxicology results. Patients can have both a psychotic
disorder and a stimulant use disorder, and if the patient still experiences ongoing psychosis despite 2–3 weeks of sobriety, a co-occurring
psychotic dis
order should be considered.
ds, or roommates and review medical records to
Addiction Centers 2022). The immunoassay in a UDS
To detect methamphetamine use, confirmatory
MANAGEMENT
Initial care must address the acute effects of stimulant use, including
cardiac issues, pulmonary issues, gastrointestinal issues, hyperthermia,
and agitation. The time course of intoxication can differentiate methamphetamine intoxication (20 hours) from other substances that cause a
sympathomimetic toxidrome, such as cocaine (30 minutes) or PCP (8
hours). Treating methamphetamine agitation is no different from any
case of agitation. Mild acute agitation can be treated with verbal deescalation, but more severe agitation should be treated with pharmacotherapy,
sedative effects, and repeated as needed (Wodarz et al. 2017). Methamphetamine-induced psychosis can be treated with higher doses of antipsychotics (Wodarz et al. 2017).
such as benzodiazepines or low-dose antipsychotics for their
Stimulant Use Disorder in Older Adults 253
Table 9–3. Causes of methamphetamine false positives on urine drug
screen
Amantadine
Bupropion
Chlorpromazine
Desipramine
Ephedrine
Fluoxetine
Labetalol
L-Methamphetamine (Vicks VapoRub)
MDMA
Methylphenidate
MDMA=3,4-methylenedioxymethamphetamine.
Source. Adapted from Brahm et al. 2010.
Phentermine
Phenylephrine
Phenylpropanolamine
Promethazine
Propranolol
Pseudoephedrine
Ranitidine
Selegiline
Thioridazine
Trazodone
As users enter the withdrawal phase, they experience intense crav-
ing for the drug as well as dysphoria with possible suicidal ideation,
p disturbances, vivid dreams, hunger, and anxiety. These effects are
slee
acutely intense and resolve in 1–2 weeks. If these short-lived symptoms
severely bother the patient, the clinician can provide information and
access to suicide prevention methods (if the patient endorses suicidal
ideation).
Patients who misuse stimulants or have a stimulant use disorder
vary widely in their readiness to cha
nge. For those who are unaware
they have a problem, clinicians can provide a brief psychoeducation intervention and assess for the patient’s stage of readiness to change by
asking patients whether there are negative consequences to their drug
use; if it is of importance to cut down on use; how likely they think they
will succeed; and how ready they are to do so (Rollnick et al. 1997;
Samet et al. 1996). The answers can help clinicians decide how to proceed next. Clinicians can use motivational interviewing to help patients
rea
ch a stage of taking action to change behavior and to maintain that
behavior. It is best when this can be done through continued clinical encounters. If a patient relapses, providers can provide support and help
the patient think about changing behaviors toward less use or recovery.
The American Society of Addiction Medicine has developed specific
patient placement criteria that can help a clinician determine what level
of care is appropriate for each patient (Gastfriend and Mee-Lee 2022). A
biopsychosocial assessment, which looks at co-occurring health conditions and what a patient needs in a recovery environment, should be
considered in determining level of care.
254 Substance Use in Older Adults
Psychoeducation of Patients and Families
Clinicians can help lessen judgment about having a stimulant use disorder by explaining a simplified neurobiology of addiction to the patient.
For example: “The same ch
during intoxication can take over a critical area of your brain called the reward pathway. This makes it very difficult for you to stop using, even
when you ar
main nonjudgmental regarding patients’ use and readiness to change.
Provid
ical and mental comorbidities, point them toward support groups and resources for more education if desired, and go over the evidence of
available trea
malize the experience and assist the patient back into a phase of recovery.
If total ab
garding harm reduction involving safety of methods of use, decreasing
amou
nts used, and decreasing the interference of stimulant use on physical health or daily function. Older adults with stimulant use disorder are
often estran
ment, the provider can also counsel family members regarding the course
of addi
Family support can drastically help a patient with any substance use
disorder, including stimulant use disorder. Family members are the
most likely to notice a change in a patient’s behavior or mood, and having family involved in the treatment plan can help patients stay abstinent longer and lessen use. Helping families understand that addiction
medical illness with brain changes, and that some people can have
is a
a genetic predisposition to developing substance use disorders, can
help lessen blame. Witnessing others misusing substances while growing up is a risk factor as well. Families can discuss any family history of
bstance use with their loved one, if relevant.
su
Having a family member with a substance use disorder can affect the
whole family, and
family therapy or counseling. Providers should also normalize and validate caregiving burden and encourage family members to prioritize their
own health as well. The clinician can help direct families to resources such
as support groups, provide information on what to do in emergency situations, and discuss when to take the patient to the emergency department.
e making conscious efforts to do so.” Clinicians should re-
ers can counsel patients regarding the course of illness and its phys-
tment. If a patient does return to use, providers should nor-
stinence is not a goal of the patient, the clinician can counsel re-
ged from family. For older adults who have family involve-
ction and their involvement in the patient’s recovery.
families should be open to treatment modalities such as
emicals that make you feel euphoric and well
Psychosocial Interventions
Psychosocial treatments, which include CBT, motivational interviewing, 12-step facilitation, contingency management, and community re-
Stimulant Use Disorder in Older Adults 255
inforcement, have been shown to be effective in treating stimulant use
disorder in multiple randomized controlled trials (RCTs). Given the
paucity of clear data to support medication-assisted treatments, psychosocial interventions—especially contingency-based approaches—
should be considered the standard of care for stimulant use disorder.
Contingency management is a behavioral therapy approach in which
individuals are rewarded, often with monetary-based reinforcement,
for positive behavioral change (Petry 2011). Community reinforcement
is a psychosocial intervention that focuses on developing healthier and
more adaptive ways to meet emotional needs than using drugs and alcohol (Meyers et al. 2011).
Two relatively recent reviews reported data summarizing psychosocial interventions. The first comprehensive review evaluated 52 trials
(N=6,923) studying multiple psychosocial interventions for stimulant
use disord
interpersonal therapy (3 studies), psychodynamic therapy (1 study),
contingency management (25 studies), and 12-step facilitation (4 studies) (Minozzi et al. 2016).
Psychosocial treatments reduced dropout rate compared with no intervention in 24 studies (N =3,393; combined relative risk [RR] 0.83; 95%
CI 0.76–0.91
end of treatment in eight studies (N=1,241; combined RR 2.14; 95% CI
0.77 to
ment as usual, psychosocial interventions reduced dropout rate to a
less
er degree in six studies (N= 516; combined RR 0.72; 95% CI 0.59–
0.89) and did not incre
ment in two studies (N=224; combined RR 1.27; 95% CI 0.94–1.72). Behavioral intervention (namely contingency management) was likely
more helpful than other psychosocial interventions. The review evaluated psychosocial interventions for stimulant use overall and did not
perform a su
A second review of 50 RCTs (N=6,942) compared the efficacy of psychosocial interventions for individuals with either cocaine or amphetamine use disorder (De Crescenzo et al. 2018). Compared with
treatment as
forcement was the only intervention that increased the number of abstinent patients at the end of treatment (odds ratio [OR] 2.84, 95% CI 1.24–
6.51, P =0.013). Contingency management plus community reinforcement was also associated with fewer dropouts than treatment as usual
at 12 week
0.001, respectively). Compared with other approaches, contingency
P<
management plus community reinforcement had the most statistically
ers: CBT (19 studies), motivational interviewing (5 studies),
). They also improved continuous abstinence rates at the
–3.59). When psychosocial treatments were compared with treat-
ase continuous abstinence by the end of treat-
bgroup analysis based on stimulant subtype.
usual, contingency management plus community rein-
s and at the end of treatment (OR 3.92, P< 0.001; and 3.63,
Соседние файлы в папке Библиотека им академика М.И. Перельмана