Chapter review

Fitzgerald PMHNP board review. ch11. Substance-related Disorders. This is drive 1 of 8. When I say Pause. Answer. wait, then I will give the answer. New section. Alcohol Withdrawal Timeline & Danger Signs. Topic. Table: Alcohol Withdrawal Stages. Fitzgerald Chapter 11 — Alcohol Withdrawal Stages and Timeline. Bottom Line Summary. * Alcohol withdrawal onset occurs within 6 to 12 hours after the last drink, peaks at 24 to 48 hours, and subsides over 5 to 7 days. * Stage 1 mild withdrawal develops at 6 to 12 hours, presenting with tremors, tachycardia, hypertension, diaphoresis, insomnia, and mild anxiety. * Stage 2 moderate withdrawal develops at 12 to 24 hours, adding motor agitation, pronounced autonomic instability, and transient visual, tactile, or auditory hallucinations with an intact sensorium. * Stage 3 withdrawal seizures peak at 24 to 48 hours as generalized tonic-clonic events; up to 30% of untreated seizure cases progress to delirium tremens. * Stage 4 severe withdrawal or delirium tremens emerges at 48 to 96 hours, causing severe confusion, fluctuating orientation, autonomic storm (fever, profuse sweating, extreme tachycardia), and carries up to a 15% mortality rate if untreated. * A CIWA-Ar score over 15 indicates severe withdrawal requiring active pharmacotherapy, while a score under 8 to 10 requires supportive care without medications. * Chlordiazepoxide and diazepam are **first-line** long-acting benzodiazepines for uncomplicated withdrawal, whereas lorazepam is **first-line** in liver failure, active hepatitis, or advanced age. * Thiamine (Vitamin B1) must always be administered before glucose to prevent acute Wernicke's encephalopathy (delirium, ataxia, and ophthalmoplegia). Alcohol Withdrawal Stages and Clinical Progression. Spoken Teaching: Stages and Timelines. Alcohol withdrawal represents a continuum of central nervous system hyperexcitability caused by abrupt cessation of alcohol's chronic GABA enhancement and NMDA glutamate suppression. When comparing the four distinct stages across time, autonomic hyperactivity links every phase, while neuro-psychiatric severity escalates sharply as time progresses. In Stage 1 (mild withdrawal occurring 6 to 12 hours post-cessation) and Stage 2 (moderate withdrawal occurring 12 to 24 hours post-cessation), patients maintain intact sensorium and orientation. What separates Stage 2 from Stage 1 is the onset of motor agitation and short-lived perceptual disturbances or hallucinations, whereas Stage 1 features isolated mild tremors, diaphoresis, tachycardia, and anxiety. In Stage 3 (withdrawal seizures occurring 12 to 48 hours post-cessation) and Stage 4 (delirium tremens occurring 48 to 96 hours post-cessation), life-threatening neuro-electrical and autonomic surges occur. Seizures peak at 24 to 48 hours and present as generalized tonic-clonic spikes. Delirium tremens emerges later at 2 to 4 days and is uniquely characterized by global disorientation, fluctuating clouding of consciousness, severe fever, and cardiovascular instability. **Safety alert**: Always administer thiamine (Vitamin B1) prior to IV glucose administration in patients with suspected or actual alcohol use disorder. Glucose loading without thiamine rapidly consumes remaining thiamine coenzymes during pyruvate oxidation, triggering or worsening acute Wernicke's encephalopathy (the clinical triad of acute delirium, gait ataxia, and ophthalmoplegia). **Board trap**: Do not assume that a low CIWA score or a history of major depression determines treatment setting. A past history of delirium tremens or alcohol withdrawal seizures is the single most prominent risk factor favoring immediate medical hospitalization rather than outpatient detoxification. **First-line**: Long-acting benzodiazepines like chlordiazepoxide and diazepam are **first-line** agents for alcohol withdrawal detoxification because their active hepatic metabolites provide a smooth auto-taper. However, in patients with severe hepatic impairment, advanced cirrhosis, or elderly individuals, lorazepam, oxazepam, or temazepam (the LOT drugs) are **first-line** because they bypass hepatic oxidation and undergo direct renal-safe glucuronidation. Clinical Assessment and Protocols. The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) evaluates 10 objective and subjective withdrawal parameters across a 0 to 67 scoring range. Scores below 8 to 10 indicate mild withdrawal requiring non-pharmacologic supportive care and frequent monitoring. Scores between 10 and 15 reflect moderate withdrawal managed with symptom-triggered benzodiazepines. Scores exceeding 15 require aggressive pharmacotherapy and inpatient medical monitoring due to high seizure and delirium risk. Sample / Example Questions in This Section. Q11. When deciding on a treatment setting to manage withdrawal symptoms for a 46-year-old man with a history of alcohol use disorder, which of the following factors is most prominent in favoring hospitalization? A. A CIWA score of less than 15. B. History of alcohol use disorder for over 2 years. C. History of major depressive disorder. D. Prior history of delirium tremens. Pause. Answer. D. Why correct: A prior history of delirium tremens or withdrawal seizures indicates high risk for severe, life-threatening autonomic withdrawal complications, requiring inpatient medical hospitalization for safe detoxification. Why the other choices are wrong: A. A CIWA score of less than 15 reflects mild-to-moderate withdrawal that can safely be managed in an outpatient setting unless severe comorbidities exist. B. A 2-year duration of alcohol use disorder describes illness chronicity but does not predict acute life-threatening withdrawal severity. C. Major depressive disorder is a common psychiatric comorbidity but does not drive immediate medical admission for withdrawal safety. Q6. Match the substance with the withdrawal symptoms below: A. Depressed mood, fatigue, vivid dreams, psychomotor agitation; B. Muscle cramps, arthralgia, diarrhea; C. Increased HR, increased BP, diaphoresis, hand tremor, agitation, hallucinations. Substances: Amphetamine, Cocaine, Alcohol, Opioid. Pause. Answer. Alcohol matches C. Why correct: Alcohol withdrawal manifests as autonomic hyperactivity including tachycardia, elevated blood pressure, diaphoresis, coarse hand tremor, psychomotor agitation, and hallucinations. Why the other choices are wrong: A. Amphetamines and Cocaine match A, presenting with a withdrawal crash involving depressed mood, profound fatigue, vivid disturbing dreams, and psychomotor changes. B. Opioids match B, producing multi-system withdrawal including abdominal cramps, diarrhea, muscle and joint pain, lacrimation, and rhinorrhea. Q4. To prevent a possible relapse by Gary, a 54-year-old man with moderate liver disease and alcohol use disorder in remission who reports increased alcohol urges following recent severe stressors, the PMHNP recommends counseling and treatment with: A. Acamprosate. B. Naloxone. C. Clonidine. D. Lorazepam. Pause. Answer. A. Why correct: Acamprosate maintains alcohol abstinence and reduces cravings by modulating glutamate and GABA pathways; it is excreted renally and is safe in patients with moderate to severe liver disease. Why the other choices are wrong: B. Naloxone is a short-acting opioid antagonist used for emergency opioid overdose reversal (Narcan), not alcohol relapse prevention. C. Clonidine is an alpha-2 adrenergic agonist used short-term to reduce autonomic symptoms during acute withdrawal, not for long-term relapse prevention or craving reduction. D. Lorazepam is a short-acting benzodiazepine indicated for acute withdrawal stabilization; using it long-term risks physical dependence, addiction, and sedation. Next. Topic. Signs of Delirium Tremens (DTs). Bottom Line Summary. * **Alcohol withdrawal timeline**: Autonomic hyperactivity and hand tremors begin within 6 to 24 hours of the last drink, withdrawal seizures peak between 12 and 48 hours, and **delirium tremens** typically emerges between 48 and 96 hours. * **Signs of delirium tremens**: **Delirium tremens** is a life-threatening medical emergency characterized by profound delirium, disorientation, severe autonomic instability, marked tachycardia, fever, hypertension, diaphoresis, agitation, and visual or tactile hallucinations. * **Primary risk factor for hospitalization**: A prior history of **delirium tremens** is the single most significant predictor of recurrent severe withdrawal and dictates immediate inpatient hospital admission. * **Clinical Institute Withdrawal Assessment**: The **CIWA-Ar** scale evaluates 10 withdrawal domains on a 0 to 67 scale, where a score of 15 or greater indicates severe withdrawal requiring aggressive medication management. * **First-line pharmacotherapy**: **Benzodiazepines** such as **lorazepam**, **chlordiazepoxide**, or **diazepam** are the gold standard to suppress central nervous system irritability and prevent seizures or DTs. * **Wernicke-Korsakoff prevention**: **Thiamine** (vitamin B1) at 100 mg to 250 mg daily must always be administered prior to intravenous **glucose** to prevent acute **Wernicke encephalopathy** and chronic **Korsakoff psychosis**. Main Testable Concepts. Progression of Alcohol Withdrawal. Alcohol withdrawal reflects acute central nervous system excitation resulting from the abrupt removal of chronic gamma-aminobutyric acid enhancement and un-inhibited N-methyl-D-aspartate glutamate receptor stimulation. Symptoms follow a predictable clinical sequence based on time elapsed since the last drink: * Mild withdrawal occurs within 6 to 24 hours and presents with anxiety, insomnia, mild tremors, diaphoresis, palpitations, and gastrointestinal upset. * Withdrawal seizures occur within 12 to 48 hours and present as brief, generalized tonic-clonic events. * Alcoholic hallucinosis occurs within 12 to 24 hours and presents with visual, auditory, or tactile hallucinations while orientation remains intact. * **Delirium tremens** occurs within 48 to 96 hours and presents with clouding of consciousness, global disorientation, severe psychomotor agitation, and autonomic hyperactivity. Assessment and Scoring with CIWA-Ar. The **CIWA-Ar** scale is a validated 10-item clinician rating tool used to quantify withdrawal severity and guide symptom-triggered dosing. * Evaluated domains include nausea and vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, and orientation. * Scores under 8 reflect mild withdrawal manageable with supportive care. * Scores between 8 and 14 reflect moderate withdrawal where symptom-triggered medication is initiated. * Scores of 15 or higher indicate severe withdrawal with a high risk for **delirium tremens**, requiring inpatient admission and protocol-driven **benzodiazepine** administration. Clinical Management and Medical Safeguards. **Safety alert**: **Delirium tremens** carries a mortality rate up to 5 percent due to cardiovascular collapse, hyperthermia, electrolyte derangements, or respiratory failure. Continuous vital sign monitoring, parenteral fluids, and continuous cardiac monitoring in an inpatient unit are required. **Board trap**: Test writers often construct stems where a malnourished or intoxicated patient receives intravenous **glucose** before **thiamine**. Administering **glucose** without **thiamine** depletes remaining thiamine cofactors during glycolysis, directly precipitating **Wernicke encephalopathy**. Always give **thiamine** before or alongside **glucose**. **Board trap**: Another frequent trap presents a patient with a low current **CIWA-Ar** score who has a documented past history of **delirium tremens**. A prior history of DTs overrides a low initial score and mandates inpatient detoxification rather than outpatient management. **First-line**: **Benzodiazepines** are the first-line drug class for managing acute alcohol withdrawal and preventing **delirium tremens**. Long-acting agents like **chlordiazepoxide** and **diazepam** provide a smooth tapering effect in patients with healthy hepatic function. Short-acting agents lacking active hepatic metabolites, specifically **lorazepam**, **oxazepam**, and **temazepam**, are preferred in patients with advanced liver disease, elevated transaminases, or elderly age. Compare and Distinguish. Alcohol Withdrawal Seizures vs Delirium Tremens. * Think: Seizures occur early with clear sensorium, whereas DTs occur late with severe delirium. * Onset timeline: Seizures peak at 12 to 48 hours post-cessation. DTs peak at 48 to 96 hours post-cessation. * Clinical presentation: Seizures are brief, self-limiting generalized tonic-clonic episodes without persistent confusion once postictal. DTs present with sustained clouding of consciousness, disorientation, terrifying hallucinations, and fluctuating vital signs. * Setting priority: Seizures require immediate acute medical evaluation, while DTs require continuous inpatient or intensive care monitoring. Wernicke Encephalopathy vs Korsakoff Psychosis. * Think: Wernicke is acute and reversible, whereas Korsakoff is chronic and irreversible. * Wernicke presentation: Acute triad of delirium, gait ataxia, and **oculomotor dysfunction** such as nystagmus or **ophthalmoplegia**. * Korsakoff presentation: Chronic neurocognitive disorder marked by severe anterograde and retrograde amnesia with confabulation. * Diagnostic logic: High-dose **thiamine** reverses Wernicke signs but cannot reverse established Korsakoff structural damage in the mammillary bodies and thalamus. Sample Test Questions. Question 1. Match the clinical withdrawal presentation below to its corresponding substance: increased heart rate, increased blood pressure, diaphoresis, hand tremor, agitation, and hallucinations. A) Amphetamine B) Opioid C) Alcohol D) Cannabis Pause. Answer. C. Why it is correct: Alcohol withdrawal causes central nervous system hyperexcitability due to the loss of GABA-mediated inhibition and unmasked NMDA glutamate receptor stimulation. Classic clinical manifestations include tachycardia, hypertension, diaphoresis, coarse hand tremors, psychomotor agitation, and visual, auditory, or tactile hallucinations. Why the other choices are wrong: * A: Amphetamine withdrawal produces a central nervous system crash characterized by depressed mood, severe fatigue, vivid unpleasant dreams, increased appetite, and psychomotor retardation or agitation. * B: Opioid withdrawal presents with multi-system autonomic and gastrointestinal hyperarousal, including lacrimation, rhinorrhea, yawning, piloerection, muscle aches, abdominal cramping, and severe diarrhea. * C: Correct option. * D: Cannabis withdrawal produces mild, non-life-threatening symptoms such as irritability, nervousness, sleep difficulty, decreased appetite, and mild abdominal discomfort without severe autonomic instability or delirium. Question 2. When deciding on a treatment setting to manage withdrawal symptoms for a 46-year-old man with a history of alcohol use disorder, which of the following factors is most prominent in favoring hospitalization? A) A CIWA score of less than 15 B) A history of alcohol use disorder for over two years C) A history of major depressive disorder D) A prior history of delirium tremens Pause. Answer. D. Why it is correct: A prior history of **delirium tremens** is the single strongest clinical predictor of recurrent severe, complicated alcohol withdrawal and DTs. This documented history mandates inpatient hospitalization for continuous medical monitoring and frequent **benzodiazepine** administration regardless of initial symptom mildness. Why the other choices are wrong: * A: A **CIWA-Ar** score under 15 indicates mild to moderate withdrawal that can generally be managed in an ambulatory outpatient setting provided close monitoring and support are present. * B: Chronicity of alcohol use disorder for two years without a personal history of severe withdrawal, seizures, or DTs does not independently require inpatient admission. * C: Co-occurring major depressive disorder requires clinical assessment and suicide risk evaluation, but it is not the primary physiological driver mandating acute inpatient medical detoxification. * D: Correct option. 🚲 Want to test your recall on the specific **benzodiazepine** selection rules for liver disease versus healthy hepatic function, or move on to the next chapter topic? Next. New section. Master Overview: Selected Substances (Table 11-17). Topic. Table: Overview — Stimulants and Opioids. Bottom Line Summary. * **Stimulant intoxication** presents with sympathetic hyperarousal including tachycardia (resting heart rate up to 140 beats per minute or higher), severe hypertension (such as 180/115 mmHg), dilated pupils (mydriasis), muscle weakness, diaphoresis, and acute paranoia or psychosis. * **Stimulant withdrawal** features a severe mood crash characterized by depressed mood, profound fatigue, vivid unpleasant dreams, psychomotor agitation or retardation, and increased appetite. * **Opioid intoxication** presents with classic central nervous system depression characterized by pupillary miosis (pinpoint pupils), respiratory depression, bradycardia, hypotension, hypothermia, and lethargy, whereas acute overdose is emergently reversed using **naloxone**. * **Opioid withdrawal** involves multi-system distress measured by the Clinical Opioid Withdrawal Scale (**COWS**), where a score of 5 to 12 indicates mild withdrawal, 13 to 24 indicates moderate withdrawal, 25 to 36 indicates moderately severe withdrawal, and greater than 36 indicates severe withdrawal. * **First-line** non-opioid symptom management for opioid withdrawal targets specific organ systems using **clonidine** for autonomic hyperactivity, **ondansetron** for nausea, **loperamide** for diarrhea, **NSAIDs** for body aches, and **trazodone** for insomnia. * **Naltrexone** (oral or monthly intramuscular **Vivitrol**) reduces alcohol and opioid cravings by blocking endogenous opioid receptors, but it is strictly contraindicated in patients actively taking opioids or scheduled for procedures requiring opioid analgesia (such as major dental surgery) due to the risk of precipitating acute severe withdrawal. * **Contingency contracting**, which utilizes tangible rewards such as gift cards for verified negative urine drug screens, is an evidence-based behavioral intervention that is especially effective for **methamphetamine use disorder**. Master Overview: Stimulants and Opioids. Pupil Findings and Autonomic Tone. * **Stimulants** (such as **dextroamphetamine**, **amphetamine**, **methamphetamine**, **methylphenidate**, and **cocaine**) stimulate sympathetic pathways, causing dilated pupils (mydriasis), tachycardia, elevated blood pressure, and diaphoresis during intoxication. * **Opioids** (such as **heroin**, **morphine**, **oxycodone**, **hydrocodone**, **fentanyl**, and **methadone**) suppress central autonomic tone, causing pinpoint pupils (miosis), bradycardia, hypotension, and respiratory depression during intoxication. * **Pupillary reversal in withdrawal**: Pupils constrict or remain normal during stimulant withdrawal, whereas pupils dilate (mydriasis) accompanied by rhinorrhea, lacrimation, piloerection (gooseflesh), and yawning during opioid withdrawal. Intoxication vs Withdrawal Contrast. * **Stimulant Intoxication vs Withdrawal**: Intoxication produces intense energy, euphoria, hypervigilance, anorexia, cardiac arrhythmias, and potential psychosis. Withdrawal produces the exact opposite physical and psychological state, marked by a severe energy crash, depressed mood, fatigue, vivid dreams, psychomotor agitation, and intense craving. * **Opioid Intoxication vs Withdrawal**: Intoxication produces analgesia, sedation, euphoria, and respiratory depression. Withdrawal produces multi-system autonomic, gastrointestinal, and musculoskeletal hyperactivity, including muscle cramps, severe joint pain (arthralgia), abdominal cramping, and profuse diarrhea. Behavioral and Pharmacotherapy Strategies. * **Stimulant Use Disorder**: No FDA-approved maintenance medication currently exists for amphetamine or cocaine dependence. Behavioral therapy, social skills training, and **contingency contracting** (rewarding negative drug screens with vouchers or gift cards) serve as primary interventions. * **Opioid Use Disorder**: Managed with medication-assisted treatment (**MAT**). **Methadone** acts as a full mu-opioid agonist, **buprenorphine** acts as a partial mu-opioid agonist, and **naltrexone** acts as an opioid antagonist to block euphoria and reduce cravings. Board Exam Signposts. * **First-line** * For non-opioid management of autonomic opioid withdrawal symptoms, **clonidine** is the **first-line** choice to suppress sympathetic overactivity. * For opioid overdose with respiratory depression, **naloxone** is the immediate **first-line** emergency reversal agent. * **Safety Alert** * **Naltrexone** must never be administered to a patient who is actively using opioids or who has scheduled elective surgery or dental procedures requiring opioid analgesics within the upcoming month, as it will precipitate severe, immediate opioid withdrawal. * **Naltrexone** is also contraindicated in patients with acute hepatitis or acute liver failure. * **Stimulant intoxication** can trigger life-threatening hypertensive crises, myocardial infarction, lethal cardiac arrhythmias, and hyperthermia. * **Board Trap** * Test writers often confuse **naltrexone** (a long-acting oral or IM opioid antagonist used for cravings in alcohol and opioid maintenance) with **naloxone** (a short-acting emergency antagonist used for acute opioid overdose reversal). * Test writers may presentationally trick candidates into prescribing **naltrexone** to a patient entering rehab without verifying upcoming medical or dental procedures that require opioid pain control. Fitzgerald Sample Test Questions. Question 1. Question: A 19-year-old man is brought to the emergency department by his friends who are concerned about his health. Physical examination reveals muscle weakness, dilated pupils, heart rate of 140 beats per minute, and blood pressure of 180/115 mmHg. His friends report he may have taken something orally about two hours ago. Which of the following is the most likely illicit substance? * A. Cannabis * B. Dextroamphetamine * C. Diazepam * D. Oxycodone Pause. Answer. Best answer: B. Dextroamphetamine Why it is correct: **Dextroamphetamine** is a central nervous system stimulant that causes sympathomimetic hyperarousal, leading to severe hypertension (180/115 mmHg), marked tachycardia (140 bpm), dilated pupils (mydriasis), diaphoresis, and muscle weakness shortly after ingestion. Why the other choices are wrong: * A. Cannabis typically causes conjunctival injection, increased appetite, dry mouth, and mild tachycardia, but does not cause severe hypertensive crisis or marked mydriasis. * B. Correct choice. * C. Diazepam is a benzodiazepine sedative that causes central nervous system depression, hypoventilation, hypotension, and sedation rather than sympathetic excitation. * D. Oxycodone is an opioid agonist that causes pupillary miosis (pinpoint pupils), respiratory depression, bradycardia, and hypotension rather than hypertension and pupillary dilation. Question 2. Question: Match the substance with the characteristic withdrawal symptoms below: Statement 1: Depressed mood, fatigue, vivid dreams, and psychomotor agitation. Statement 2: Muscle cramps, arthralgia, and diarrhea. Statement 3: Increased heart rate, elevated blood pressure, diaphoresis, hand tremor, agitation, and visual or tactile hallucinations. Which substance corresponds to Statement 1? * A. Amphetamine * B. Opioid * C. Alcohol * D. Cannabis Pause. Answer. Best answer: A. Amphetamine Why it is correct: Withdrawal from stimulants such as **amphetamine** or **cocaine** produces a characteristic psychological and physical crash marked by depressed mood, severe fatigue, vivid unpleasant dreams, increased appetite, and psychomotor agitation or retardation. Why the other choices are wrong: * A. Correct choice. * B. Opioid withdrawal (Statement 2) presents with multi-system physical symptoms including muscle cramps, joint aches (arthralgia), rhinorrhea, lacrimation, nausea, abdominal cramping, and diarrhea. * C. Alcohol withdrawal (Statement 3) presents with autonomic hyperactivity including tachycardia, elevated blood pressure, diaphoresis, coarse hand tremors, psychomotor agitation, and potential delirium tremens or hallucinations. * D. Cannabis withdrawal produces mild irritability, restlessness, anxiety, sleep disturbance, and reduced appetite, but not the classic severe depressive crash with vivid dreams seen in stimulant withdrawal. Question 3. Question: Dana, a 44-year-old registered nurse, is preparing to be discharged from a 30-day inpatient treatment facility for alcohol and methamphetamine dependence. She wishes to start a medication to help maintain abstinence from alcohol. She has extensive dental work planned to begin within the next month. Which medication would be contraindicated for use given this information? * A. Disulfiram * B. Naltrexone * C. Acamprosate * D. Sertraline Pause. Answer. Best answer: B. Naltrexone Why it is correct: **Naltrexone** is an opioid receptor antagonist. Because Dana has extensive dental surgery scheduled in the upcoming month that will likely require opioid analgesics for pain management, **naltrexone** is strictly contraindicated because it would block the analgesic effects of prescribed opioids or precipitate acute withdrawal. Why the other choices are wrong: * A. Disulfiram is an aldehyde dehydrogenase inhibitor used for alcohol aversion; it does not block opioid receptors and is not contraindicated by upcoming pain management, though it requires strict avoidance of alcohol. * B. Correct choice. * C. Acamprosate restores GABA and glutamate balance to maintain alcohol abstinence and is excreted renally; it does not interact with opioid receptors and can be safely used alongside planned surgical or dental procedures. * D. Sertraline is an SSRI antidepressant that does not treat alcohol cravings directly, but it is not contraindicated by upcoming dental procedures or opioid use. Next. Topic. Table: Overview — Cannabis and Hallucinogens. Bottom Line. - **Cannabis** metabolites are lipophilic and remain detectable in urine for up to **1 month** in regular users smoking 2 to 3 days per week. - **Cannabis** use in adolescents and young adults with underlying psychiatric vulnerability can precipitate or exacerbate **schizophrenia** and psychotic symptoms. - Therapeutic applications for **THC** include **nausea**, **chronic pain**, **HIV** or **AIDS** cachexia, **cancer**, **glaucoma**, **multiple sclerosis**, and **epilepsy**. - **Cannabis** tolerance develops with regular use, but physical dependence is low. Withdrawal manifests as **irritability**, **restlessness**, **insomnia**, **anorexia**, and **mild nausea**. - **Hallucinogens** include naturally occurring **psilocybin** and **mescaline**, alongside synthetic agents such as **LSD**, **PCP**, **MDMA**, and **ketamine**. - **Hallucinogens** alter serotonin and glutamate neurotransmission, producing profound perceptual distortions, synesthesias, and depersonalization without causing a physical withdrawal syndrome. - Psychedelic substances like **ketamine** and **psilocybin** are utilized or investigated for **treatment-resistant depression**, **PTSD**, and **substance use disorders**. Spoken Teaching: Cannabis and Hallucinogens. Signposts. - **Safety alert:** **Cannabis** use in vulnerable adolescents and young adults significantly increases the risk of unmasking or worsening **schizophrenia** and psychotic spectrum disorders. - **Board trap:** Confusing urine screening elimination windows. Single use clears rapidly, but regular use 2 to 3 days per week stores **THC** in adipose tissue, causing positive urine screens for up to **1 month**. - **First-line:** Intoxication management for **cannabis** or **hallucinogens** focuses on supportive care, a calm low-stimulation environment, physical safety, and symptom control. Cannabinoids (Cannabis). - Neuropharmacology and Desired Effects: **THC** acts on central cannabinoid receptors. Desired effects include euphoria, relaxation, heightened sensory perception, and appetite stimulation. - Approved and Medical Indications: Medical cannabis serves patients with **nausea**, **chronic pain**, **HIV** or **AIDS** cachexia, **cancer**, **glaucoma**, **multiple sclerosis** spasticity, and **epilepsy**. - Adverse Effects and Risks: Heavy chronic use is linked to chronic respiratory conditions, lung disease, cerebral structural alterations, executive function deficits, and heightened seizure susceptibility. - Dependency and Withdrawal Profile: Tolerance develops over time. True physical dependence is minimal. Withdrawal features mild **irritability**, **restlessness**, **insomnia**, **anorexia**, and **mild nausea**. - Urinary Elimination Timeline: Regular consumption of 2 to 3 days per week extends urine metabolite excretion up to **1 month**. Hallucinogens (Psychedelics). - Naturally Occurring and Synthetic Classes: Naturally derived agents include **psilocybin** from mushrooms and **mescaline** from peyote cactus. Synthetic and pharmaceutical agents include **LSD**, **PCP**, **MDMA**, and **ketamine**. - Clinical Presentation of Intoxication: Hallucinogenic intoxication features visual illusions, synesthesias, derealization, depersonalization, **pupillary dilation**, **tachycardia**, sweating, tremors, and incoordination. - Dependence and Withdrawal Mechanics: Hallucinogens produce rapid psychological tolerance and psychological dependence. They do not produce physical dependence or a physical withdrawal syndrome. - Therapeutic Integration: Clinical application of **ketamine** and **psilocybin** includes **ketamine-assisted psychotherapy** for **treatment-resistant depression**, **PTSD**, and **alcohol use disorder**. States like Oregon have legalized **psilocybin** for regulated therapeutic environments. Fitzgerald Sample Questions. Question 1. Sarah, a 27-year-old, smokes one marijuana cigarette on average 2 to 3 days per week. She weighs 145 pounds (65.77 kg). She decides to stop smoking for a job interview that includes a urine drug screen. Detection of **cannabis** in her urine can last up to: - A. 1 week - B. 2 weeks - C. 1 month - D. 6 months Pause. **Answer:** C **Why it is correct:** **Cannabis** metabolites are highly lipophilic and store in body fat stores. In a regular user who smokes 2 to 3 days per week, **THC** metabolites release slowly into urine, remaining detectable for up to **1 month**. **Why the other choices are wrong:** - A. 1 week reflects urine detection windows for infrequent single-use, not multi-day weekly consumption. - B. 2 weeks underestimates the extended tissue half-life seen in regular weekly users. - D. 6 months exceeds standard urine excretion windows for cannabinoids. **Test-taking pearl:** Lipophilicity causes **THC** to sequester in adipose tissue, extending urine detection to 30 days in regular users. **Concept tested:** **Cannabis** urine drug screen detection window. 💡 **Next Study Step:** Review the **Opioids and Sedatives** sections of **Fitzgerald Chapter 11** to contrast multi-system withdrawal management (**COWS** and **CIWA**) against non-physical withdrawal profiles. Next. End of this drive.