Aafp july 15 2018 cme quiz pdf download

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 month period: The stimulant is often taken in larger amounts over a longer period than was intended.

A great deal of time is spent in activities necessary to obtain the stimulant, use the stimulant, or recover from its effects. Recurrent stimulant use resulting in a failure to fulfill major role obligations at work, school, or home. Continued stimulant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the stimulant. Important social, occupational, or recreational activities are given up or reduced because of stimulant use.

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. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the stimulant to achieve intoxication or desired effect.

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 for stimulant withdrawal. The stimulant or a closely related substance is taken to relieve or avoid withdrawal symptoms. Specify if : In a controlled environment: This additional specifier is used if the individual is in an environment where access to stimulants is restricted.

Reprinted with permission from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.

Laboratory diagnosis is not necessary but is often used in conjunction with the history and physical examination for initial diagnosis and to monitor for abstinence. Urine screening immunoassays are inexpensive and provide rapid results. However, the sample can be easily tampered with by the patient, many of the substances may cross-react with other drugs or medications, and the duration for detection is variable.

Cocaine is the drug least likely to have a false-positive result by measuring its major metabolite, benzoylecgonine. Cocaine is typically detectable in the urine for two to three days, but this can vary based on usage. Tests for methamphetamines often yield false-positive results because of cross-reactivity with decongestants and appetite suppressants.

Urine pH affects the excretion of amphetamines, and ingestion of large quantities of bicarbonate will reduce the ability to detect them. The typical time frame for detection by urine immunoassay is one to three days. Newer designer drugs such as synthetic cannabinoids and bath salts are not detected by routine drug screening. Although they can be identified by liquid and gas chromatography—mass spectrometry, these tests are not available at most laboratories, and the lengthy turnaround time makes them less useful clinically.

Cocaine has many street names and comes in two forms: base and salt, each having the same cocaine molecule and pharmacologic action at the brain or target organ, but different routes of administration. It vaporizes when heated, which allows it to be smoked. Cocaine salt is a fine white powder that can be snorted or mixed with water and injected. Cocaine's onset of action varies with the route of administration, with more rapid onset after the drug is smoked or injected.

Effects last less than 30 minutes. Intranasal use has a delayed onset with effects lasting approximately 60 minutes. Users frequently readminister to maintain the desired effects. Table 3 lists short- and long-term health effects of cocaine use.

Cocaine 5 , 19 , 24 , Acute MI, aortic dissection, cerebrovascular accidents ischemic and hemorrhagic , crack lung diffuse alveolar damage , seizures, tactile hallucinations e. Cardiomyopathy, memory loss, movement disorders, perforated nasal septum, psychiatric disorders. Methamphetamine Acute MI, insomnia, psychotic symptoms e.

Extreme weight loss, impaired verbal learning and motor skills, infectious diseases, psychiatric disorders, tooth decay, violent behavior. Arrhythmias, distortion of sensory and time perception, hypertension, hyperthermia, increased muscle rigidity. Acute MI, agitation, aortic dissection, bruxism, paranoia, rhabdomyolysis, serotonin syndrome. Synthetic cannabinoids 25 , Information from references 5 , 19 , and 24 through A Cochrane review concluded that compared with usual treatment typically group counseling or case management , psychosocial therapy improved adherence and increased abstinence for adults using cocaine.

Psychosocial interventions evaluated included individual or group counseling, intensive outpatient therapy, cognitive behavior therapy, and motivational interviewing. Resources vary by geographic region, and clinicians should acquaint themselves with local resources.

No medications have been approved by the U. Food and Drug Administration for the treatment of cocaine use disorder. Substitution therapy replacing an illegal drug with a legal, oral, longer-acting drug that has lower addiction potential, such as methylphenidate [Ritalin] or amphetamine salts seems promising for cocaine use disorder.

However, a Cochrane review concluded that evidence does not clearly demonstrate effectiveness, and that more high-quality studies are needed. Most illicit methamphetamine used in the United States is at much higher doses than for medicinal use and is manufactured in illegal laboratories.

It can also be made in small clandestine laboratories with ingredients such as pseudoephedrine. Methamphetamine can be taken orally, smoked, snorted, or dissolved in water or alcohol and injected. Like cocaine, methamphetamine blocks the reuptake of monoamine neurotransmitters. However, methamphetamine also stimulates the release of dopamine into synapses and has a much longer duration of action than cocaine.

Methamphetamine causes many of the same clinical effects as other stimulants Table 3. Although no medications are approved for treatment of methamphetamine use disorder, a few have shown promise. A randomized controlled trial enrolled 60 men who have sex with men; participants had methamphetamine use disorder and were actively using the drug.

Men in the mirtazapine group had decreased methamphetamine use and sexual risk, despite low adherence. Another randomized controlled trial found no overall improvement with bupropion. It acts as both a stimulant and a psychedelic, inducing feelings of increased energy and pleasure, especially from tactile stimulation. It is generally taken in pill form, but is sometimes snorted or ingested as a liquid.

The effects of MDMA last about three to six hours, and doses are often repeated to maintain effects. MDMA stimulates the release of dopamine, serotonin, and norepinephrine, as well as cortisol, oxytocin, and antidiuretic hormone. MDMA causes a fold greater serotonin release than methamphetamine, which induces intense mood effects.

Serotonin syndrome and hyponatremia are possible consequences of MDMA toxicity. Hyponatremia can result from dilutional effects of water overconsumption from thirst and overheating, in addition to increased free water absorption at the kidneys due to increased levels of antidiuretic hormone.

The addiction potential of MDMA has not been well studied. Cognitive behavior therapy and recovery support groups are used for patients with MDMA use disorder. Synthetic cannabinoids are compounds with cannabinoid-like action, but a different chemical structure than marijuana-derived cannabinoids. These compounds are sprayed onto dried, shredded plant material to be smoked or available as liquids to be vaporized and inhaled in electronic delivery devices.

They have been sold in convenience stores or online as incense; the chemical formulation frequently changes to avoid detection by standard drug tests and regulatory efforts. Synthetic cannabinoids are direct agonists with a high affinity for the cannabinoid type 1 CB 1 receptor, as opposed to tetrahydrocannabinol, which is a partial agonist of the CB 1 and CB 2 receptors.

This difference can lead to more intense and long-lasting effects. Acute intoxication and withdrawal syndromes from synthetic cannabinoids may require hospitalization because of severe cardiac, respiratory, and seizure complications. Because chemical composition of synthetic cannabinoids varies from batch to batch, and because they may be mixed with other substances, clinical and mind-altering effects vary considerably.

Synthetic cannabinoids are thought to be addictive, and withdrawal symptoms may include headaches, anxiety, depression, and irritability. Although there are no studies of treatments for synthetic cannabinoid use, studies are available for cannabis use disorder. Compared with minimal or inactive treatment controls, psychosocial interventions reduce the frequency of use and severity of dependence in frequent users of cannabis.

It is not known if these findings are generalizable to synthetic cannabinoid use disorder. A Cochrane review found insufficient evidence to recommend selective serotonin reuptake inhibitors, bupropion, buspirone Buspar , or norepinephrine reuptake inhibitors in the treatment of cannabis use disorder.

However, it is not known if these findings would be applicable for synthetic cannabinoid use disorder. They are marketed as cheap substitutes for other stimulants. Synthetic cathinones are usually sold as a white or brown crystal-like powder, and may be labeled as bath salts, plant food, or jewelry cleaner.

They may be swallowed, snorted, smoked, or injected to produce desired stimulant effects, including increased sociability and libido. An animal study found that 3,4-methylenedioxypyrovalerone MDPV , the most common synthetic cathinone found in patients admitted to emergency departments, has an effect on the brain that is 10 times more powerful than cocaine. Although suicide rates increased among persons in all age groups younger than 75 years, adults 45 to 64 years of age had the largest absolute rate increase from Family physicians have a role in preventing suicide by screening all adults for depression, providing further evaluation for those who screen positive, and facilitating appropriate treatment.

The CDC offers tips to help prevent suicide that family physicians can pass along to patients, such as learning about the warning signs of suicide to identify and appropriately respond to persons at risk, reducing access to lethal means e. Americans with high-deductible health insurance plans but no health savings accounts HSAs are less likely to see family physicians, receive preventive care, or seek subspecialty services, according to researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

In a first-of-its-kind national study published in the May 23 issue of Translational Behavioral Medicine , researchers pooled data from the to Medical Expenditure Panel Survey for 25, privately insured adults 18 to 64 years of age were examined and divided into four insurance types: 1 no deductible; 2 low deductible; 3 high deductible with an HSA; and 4 high deductible without an HSA.

The study establishes that high-deductible plan enrollees without HSAs see family physicians less often and lose opportunities for preventive care. Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. This content is owned by the AAFP. When delivering bad news, provide a setting that assures privacy, limits interruptions, and involves family, if the patient desires.

When delivering bad news, use nontechnical words and avoid medical jargon. Provide empathy; avoid being blunt and allow time for patients to express emotions.

When delivering bad news, respond to patients' emotions as they arise, use empathic statements, validate responses, and ask exploratory questions when the emotion is unclear. Use training programs such as communications courses, standardized patient scenarios, and interactive computer courses to improve skills in delivering bad news. In the paternalistic patient-care model, the physician acts as the patient's guardian, providing selected information to steer the patient to what the physician identifies as the best decision.

There has also been increased study of patient preferences in an effort to move toward evidence-based guidelines.

Most patients prefer to know their diagnosis, but the amount of information they want varies among demographics. For example, younger patients, female patients, and patients with higher education levels tend to desire more detailed information. For example, one study found that Korean Americans and Mexican Americans are more likely to favor a family-centered medical decision model; in contrast, African Americans and European Americans prefer a model with more individual patient autonomy.

Patients prefer to receive bad news in person with the physician's full attention, and they want to be confident in the physician's skill. Compared with a century ago, when most deaths occurred in the home, most deaths now occur in a hospital or facility. Because many persons lack firsthand experience with death, discussing it may be more difficult.

Patients have unrealistic expectations of health and life, perhaps secondary to overplayed media reports of medical advances or unrealistic television portrayals. For example, the fictional survival rate of cardiopulmonary resuscitation portrayed on television is twice that of real-life statistics.

Physicians experience stress related to providing bad news, and this stress often extends beyond the actual conversation. Physicians also fear that delivering truthful news about a terminal illness will leave a patient depressed, without hope, and with a shortened life span if hospice is involved.

Physicians, for a variety of reasons e. The SPIKES protocol, initially developed to guide oncologists in delivering bad news to patients with cancer, may also be used with children.

Advanced preparation Review the patient's history, mentally rehearse, and emotionally prepare. Arrange for a support person if the patient desires. Determine what the patient knows about his or her illness.

Provide seating for everyone. Maintain eye contact and sit close enough to touch the patient, if appropriate. Communicate well Avoid medical jargon, and use plain language. Allow for silence, and move at the patient's pace.

Deal with patient and family reactions Address emotions as they arise. Actively listen, explore feelings, and express empathy. Encourage and validate emotions Correct misinformation.

Explore what the bad news means to the patient. Be cognizant of your emotions and those of your staff. Beyond breaking bad news: how to help patients who suffer. West J Med. Background Know the patient's background, clinical history, and family or support person. Rapport Build rapport, and allow time and space to understand the patient's concerns. Explore Determine the patient's understanding, and start from what the patient knows about the illness. Announce Preface the bad news with a warning; use nonmedical language.

Avoid long explanations or stories of other patients. Give no more than three pieces of information at a time. Kindle Address emotions as they arise. Ask the patient to recount what you said. Be aware of denial. Summarize Summarize the bad news and the patient's concerns. Provide a written summary for the patient. Ensure patient safety e. Information from reference Arrange for a private room or area.

Have tissues available. Limit interruptions and silence electronics. Allow the patient to dress if after examination. Maintain eye contact defer charting. Include family or friends as patient desires. Use open-ended questions to determine the patient's understanding.

Correct misinformation and misunderstandings. Identify wishful thinking, unrealistic expectations, and denial. Determine how much information and detail a patient desires. Ask permission to give results so that the patient can control the conversation. If the patient declines, offer to meet him or her again in the future when he or she is ready or when family is available. Briefly summarize events leading up to this point. Provide a warning statement to help lessen the shock and facilitate understanding, although some studies suggest that not all patients prefer to receive a warning.

Use nonmedical terms and avoid jargon. Stop often to confirm understanding. Stop and address emotions as they arise. Use empathic statements to recognize the patient's emotion. Validate responses to help the patient realize his or her feelings are important. Ask exploratory questions to help understand when the emotions are not clear.

Summarize the news to facilitate understanding. Set a plan for follow-up referrals, further tests, treatment options. Offer a means of contact if additional questions arise. When you do, write them down and we can review them when we meet again.