ABPN Addiction Psychiatry cheat sheet

The mesolimbic dopamine projection from the ventral tegmental area to the nucleus accumbens mediates acute drug reward and is modulated by glutamatergic, GABAergic, opioid, and endocannabinoid inputs.

Chronic substance use is associated with downregulated striatal D2 dopamine receptors and blunted response to natural rewards, contributing to anhedonia and persistent use.

Twin and family studies estimate heritability of alcohol use disorder near 50%; nicotine and opioid dependence are also substantially heritable and polygenic, with gene-environment interaction.

DSM-5 tolerance and withdrawal are not counted toward substance use disorder criteria when they occur during appropriate prescribed use of a medication such as an opioid or benzodiazepine.

Pharmacodynamic tolerance reflects receptor desensitization or downregulation, whereas pharmacokinetic tolerance reflects increased metabolism, such as CYP2E1 induction by chronic ethanol exposure.

Withdrawal often produces effects opposite to acute intoxication, such as hyperalgesia and autonomic hyperactivity after opioids, consistent with opponent-process and allostatic adaptation.

Buprenorphine is a high-affinity mu-opioid partial agonist that produces submaximal receptor activation, reduces craving, and can precipitate withdrawal by displacing full agonists.

Methadone and buprenorphine are CYP3A4 substrates; azole antifungals inhibit CYP3A4 and raise levels, while rifampin induces CYP3A4 and can lower levels enough to precipitate withdrawal.

DSM-5 substance use disorder uses 11 criteria; 2-3 criteria indicate mild, 4-5 moderate, and 6 or more severe disorder.

DSM-5 removed recurrent legal problems and added craving as a criterion; tolerance and withdrawal count only when not solely attributable to prescribed use.

AUDIT-C uses three alcohol items; a score of 4 or more in men or 3 or more in women is generally positive, with lower thresholds sometimes used in older adults.

CAGE has four yes/no items; two or more affirmative answers suggest an alcohol problem, but sensitivity is limited in some settings and populations.

DAST-10 scores of 3-5 suggest moderate problems and 6 or more suggest substantial problems related to drug use.

CIWA-Ar scores of 8-15 indicate moderate alcohol withdrawal and scores above 15 indicate severe withdrawal; thiamine should be given before glucose to reduce Wernicke encephalopathy risk.

COWS scores of 13-24 indicate moderate opioid withdrawal; buprenorphine initiation is typically timed to mild-to-moderate withdrawal to avoid precipitated withdrawal.

Urine cocaine metabolite is usually detectable for 2-4 days, while chronic cannabis use can remain detectable for weeks; interpretation requires attention to cutoffs and false positives.

Naltrexone 50 mg daily reduces heavy drinking; acamprosate 666 mg three times daily supports abstinence and is preferred when liver disease limits naltrexone; disulfiram requires supervised adherence.

Methadone and buprenorphine reduce mortality in opioid use disorder; buprenorphine/naloxone is common in outpatient practice, methadone is preferred in pregnancy, and naltrexone requires 7-10 days opioid-free.

Naloxone reverses opioid-induced respiratory depression; repeat doses may be needed because naloxone duration is shorter than that of many opioids, and ventilatory support remains essential.

Varenicline is a first-line smoking cessation medication; combination nicotine replacement and bupropion are alternatives, with choice guided by contraindications and patient preference.

Benzodiazepine dependence is managed with a gradual taper, often reducing the dose by 10-25% every 2-4 weeks; abrupt cessation risks seizures and severe withdrawal.

CBT, motivational interviewing, contingency management, 12-step facilitation, and family therapies are evidence-based psychosocial treatments with different targets and evidence strengths.

Alcohol withdrawal is treated first-line with benzodiazepines; phenobarbital is an alternative, and dosing is guided by withdrawal severity and monitoring for complications.

Stimulant use disorder has no FDA-approved medication; contingency management is the most effective established psychosocial treatment for promoting abstinence.

Opioid use disorder in pregnancy is treated with methadone or buprenorphine maintenance; medically supervised withdrawal is not recommended because relapse risk outweighs fetal benefit, and neonatal opioid withdrawal should be anticipated.

Adolescent substance use treatment emphasizes family-based therapy, motivational enhancement, and contingency management; buprenorphine is approved for opioid use disorder in patients aged 16 years and older.

Older adults have lower body water and reduced hepatic metabolism, raising blood alcohol concentrations; alcohol interacts with benzodiazepines, opioids, and anticoagulants, and screening cutoffs may be lower.

Integrated dual diagnosis care treats substance use and psychiatric disorders in the same setting and improves engagement compared with sequential or parallel care for severe co-occurring illness.

In advanced liver disease, acamprosate is preferred over naltrexone; disulfiram is contraindicated, and naltrexone should be avoided in acute hepatitis or hepatic failure.

Acamprosate is contraindicated when creatinine clearance is below 30 mL/min and requires dose adjustment in moderate renal impairment.

SBIRT identifies risky substance use in medical settings; brief motivational intervention suits mild risk, while dependence requires specialty referral and medication evaluation.

Buprenorphine can be prescribed in primary care without a special waiver after 2023; methadone remains dispensed through opioid treatment programs, and telehealth improves access and retention.