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🏠11. Toxicology and Substance Use Disorder

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Question Bank

1
What is toxicology?
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study of harmful effects of physical and chemical agents

2
What is acute toxicity?
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Single exposure to a toxic substance, such as a snake bite.

3
What is chronic toxicity?
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Multiple exposure to a toxic substance

4
What is delayed-onset toxicity?
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Toxicity after an interval following exposure

5
What are toxidromes?
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set of symptoms that can be caused by specific drugs or toxins

6
Possible causes of HT and Tachycardia
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Amphetamines, cocaine, nicotine and antimuscarinic drugs

7
Possible causes of HypoT and bradychardia
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Opioids, Clonidine, sedatives-hypnotics, β-blockers

8
Possible causes of flaccid coma
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Opioids sedatives/hypnotics

9
Possible causes of dysarthria, ataxia, nystagmus
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Phenytoin, alcohol and sedatives

10
Possible causes of ileus (bowl obstruction)
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Antimuscarinics, opioids and sedatives

11
What are the major deleterious effects of chronic lead exposure, especially for children?
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Impaired bone formation and developmental issues

12
What are some sources of lead exposure?
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Sources include exposure to old paint, industrial pollution, contaminated water, and contaminated dust.

13
What are the early signs of lead exposure?
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constipation and a metallic taste in the mouth

14
What is a sign of lead poisoning
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Burton’s line

15
What are the CNS effects of lead intoxication?
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Headaches, confusion, fatigue, and impaired concentration.

16
How does lead intoxication affect erythrocyte life span?
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It shortens the erythrocyte life span

17
What is the treatment for lead intoxication?
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Chelation therapy

18
What are the three forms of mercury mentioned in the slide?
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Elemental, inorganic salts, and organic salts

19
How is elemental mercury absorbed?
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By inhalation, liquid at room temp

20
What are inorganic mercury salts?
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Mercuric or mercurous salts absorbed via dermal route

21
What are organic mercury salts
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methylmercury lipid soluble form that permeate cell membrane and BBB

22
What are the symptoms of mercury poisoning?
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Neurotoxicity, nephrotoxicity, excessive salivation, irritability, and teratogenicity.

23
What are the effects of acute high-level exposure to mercury vapor?
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Corrosive inflammation of upper + lower respiratory tract nephrotoxic and neurotoxic effects

24
What is Minamata disease?
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Neurological syndrome caused by chronic mercury poisoning, ataxia, muscle weakness, loss of hearing and vision

25
What are the recommended guidelines for minimizing mercury exposure in the dental environment?
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• pre-encapsulated amalgam preparations with PPE • recycled and properly dispose of capsules • use Amalgam separator traps

26
What are the sources of fluoride poisoning?
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• Water with high fluoride content (>1ppm) • accidental ingestion of fluoride supplements • fluorine-containing insecticides

27
Age group most susceptible to fluoride poisoning
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Children (<6 years) from toothpaste or mouthwash ingestion

28
What are the symptoms of acute fluoride toxicity?
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GI disturbances Severe cases: renal and cardiac failure, coma

29
What causes chronic toxicity (fluorosis)?
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High concentrations in water chronic use of fluoride supplements

30
What are the consequences of severe chronic toxicity (fluorosis)?
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Skeletal fluorosis fragile bones → risk of fractures possible joint damage

31
What is the mechanism of action of fluoride in dental fluorosis?
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• Amelogenin binds to fluoridated hydroxyapatite • interferes w/ matrix proteinase • fluoride can cause apoptosis of ameloblast

32
What are the acute management steps for dental fluorosis?
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IV fluid, calcium, and symptom control.

33
Carbon monoxide poisoning patho
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carbon monoxide bind to oxygen-binding sites in Hb forms carboxyhemoglobin leading to ischemic injuries

34
Carbon monoxide poisoning symptoms
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headache, dyspnea, tachycardia, fatality

35
What is the recommended daily dosage of acetaminophen?
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not exceed 4 g/day

36
What are the four phases of acetaminophen toxicity?
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Phase 1: 0 to 24 hours Phase 2: 24 to 72 hours Phase 3: 72 to 96 hours Phase 4: > 4 days to 2 weeks

37
At what level does acetaminophen toxicity develop?
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7.5 - 10 g/day and it is exacerbated by alcohol use

38
What is N-acetyl-P-benzoquinolone imine (NAPQI)?
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A toxic metabolite of acetaminophen produced by CYP450

39
Mechanism of acetaminophen toxcity
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Excess acetaminophen = saturation of metabolic pathway → accumulation of excess NAPQI → liver injury + hepatocyte damage

40
What is the antidote for acetaminophen overdose?
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N-acetylcysteine

41
Causes of Salicylates toxicity
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1. Aspirin 2. Oil of Wintergreen 3. bismuth subsalicylate

42
What is the maximum daily dose of aspirin?
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4 g/day

43
when does Acute Salicylate toxicity develop
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few hours after large single overdose (100 mg/dl or around 10 gm)

44
What are the symptoms of salicylism?
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Tinnitus, hearing loss, vomiting, vertigo.

45
What is the treatment for salicylate toxicity?
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Administration of charcoal urine alkylation by sodium bicarbonate

46
What is Kava kava?
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Kava kava is a herbal supplement derived from the roots of Piper methysticum.

47
What are the uses of Kava kava?
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recreational drink in some countries herbal supplement to treat anxiety, insomnia, decrease hypertension, pain management, and kidney cleanser

48
What are the adverse effects of Kava kava?
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acute liver injury that can lead to fatal complications

49
What is hemodialysis and how does it enhance the elimination of certain medications/toxins?
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blood is filtered through a dialyzer to remove waste products and excess fluids elimination of certain medications/toxin by filtering them out of the blood

50
How does urinary alkalization enhance the elimination of salicylates?
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• increasing urine pH with IV sod. bicarb • transforms salicylates into an ionized form • ↑ renal excretion and reduces toxicity

51
What is activated charcoal and how does it enhance elimination
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highly porous material w/ large surface area adsorbs medications, enhancing their elimination

52
What is a substance use disorder?
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Excessive use of illicit substances leading to social, academic, and occupational impairment

53
Time criteria for diagnosis SUD
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>2 symptoms in past 12 months

54
What are the 11 diagnostic criteria for Substance Use Disorder (SUD) according to DSM-V?
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1. Larger amounts/ longer period 2. Desire to stop 3. Spending a lot of time 4. Cravings 5. Failure to fulfill responsibilities 6. Giving up important activities 7. Recurrent use 8. Continuous use despite physical/psychological problems 9. Continuous use despite relationship problems or work obligations 10. Tolerance 11. Withdrawal symptoms

55
What are the three categories of SUD based on the number of symptoms?
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Mild, Moderate, Severe

56
What defines a Mild SUD?
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Presence of 2-3 symptoms in the past 12 months

57
What defines a Moderate SUD?
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Presence of 4-5 symptoms in the past 12 months

58
What defines a Severe SUD?
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Presence of 6 or more symptoms in the past 12 months

59
What percentage of patients diagnosed with SUD received treatment in 2020?
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6.5%

60
How many people died from drug overdoses in 2023?
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105,000

61
!0 classes of substances
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• Alcohol • Tabacco • Caffeine • Cannabis/Marijuana • Heroin • Fentanyl • Opioids • Sedatives, hypnotics • Stimulants • Inhalants

62
Risk factors for SUD
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Multifactorial • psychological • biological • socio-cultural • environmental factors

63
Examples of risk factors
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psychiatric disorders genetic factors adverse childhood experiences

64
What are the four stages of substance use disorder (SUD) pathophysiology?
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Pleasure or reward effect Dependence Tolerance Stopping lead to withdrawal

65
What is the primary component responsible for alcohol's effects?
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Ethanol content

66
What is the main site of ethanol absorption in the body?
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Proximal portion of the small intestine (duodenum/jejunum)

67
What is the first metabolite produced from ethanol in the liver?
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Acetaldehyde

68
What enzyme is responsible for the metabolism of ethanol in the liver?
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Alcohol dehydrogenase

69
What is the impact of ethanol on the brain?
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Ethanol initially has a rewarding and relaxing effect then decreases cognitive function and movement coordination

70
How does ethanol affect the brain's neurotransmitter systems?
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GABA agonist glutamate antagonist

71
Ethanol's effect on neurotransmitters
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• activates opioid receptors • release of endorphins • triggers release of dopamine and serotonin

72
Ethanol effect on medulla
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decrease respiratory rate and reduce consciousness

73
At what level does alcohol intoxication typically develop?
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BAC: 0.16-0.3 % slurred speech, vomiting, amnesia

74
What is the BAC level that leads to respiratory suppression and death?
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> 0.31 %

75
What are the long-term complications of chronic alcoholism?
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Psychiatric: dependence and withdrawal symptoms Physical: • arrhythmia, cardiomyopathy • inflammation of liver • pancreatitis • cancers Excessive large doses: • cardiac and respiratory depression •unconsciousness •death

76
What are the symptoms of alcohol withdrawal?
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Anxiety, depression, irritability, fatigue, tremors, difficulty sleeping, vomiting, and seizures.

77
What is delirium tremens and what are its symptoms?
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severe complication of alcohol withdrawal high fever, intense agitation, visual hallucinations, and tactile hallucinations

78
Alcohol cessation strategies
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Non-pharm: CBT Pharm: disulfiram and naltrexone

79
What is the mechanism of action of Disulfiram in alcohol cessation?
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inhibits alcohol metabolism inhibiting acetaldehyde dehydrogenase → build-up of acetaldehyde + hangover

80
What is the effect of prescribing opioids in patients receiving Naltrexone?
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Prescribing opioids in patients receiving Naltrexone will diminish opioid activity.

81
What are the side effects of disulfiram?
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nausea, flushing, vomiting, headache, and unpleasant effects

82
What are the symptoms of ethanol intoxication in young children?
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Severe to fatal hypoglycemia leading to hypoglycemic seizures and death.

83
What are the symptoms of ethanol intoxication in adolescents?
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Slurred speech, incoordination, unsteady gait, memory impairment, and CNS depression. Hypoglycemia may occur.

84
What is the management of ethanol intoxication?
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Airway, breathing, oxygen, dextrose (hypoglycemia), and fluids.

85
What is methanol and what are its effects?
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carcinogenic and toxic alcohol causes retinal injury, seizures, and blindness

86
What is the mechanism of methanol intoxication and what is the antidote?
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oxidized to formic acid, lead to permanent blindness Antidote: Fomepizole inhibits methanol oxidation to formic acid

87
What is Nicotine Use Disorder?
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continued use of nicotine despite negative consequences

88
What are two health risks associated with smoking?
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Myocardial infarction and stroke.

89
What are the effects of formaldehyde on the body?
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Causes endothelial cell damage and various inflammatory reactions

90
What is nicotine?
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Primary component of tobacco that drives tobacco addiction

91
What is the primary route of absorption for nicotine?
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Inhalation from lung alveoli

92
What are the effects of nicotine on neurotransmitters in the CNS?
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Nicotine triggers the release of glutamate and dopamine.

93
Effects of low doses of nicotine
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some euphoria and arousal improves attention, learning, problem solving, and reaction time

94
High doses of nicotine
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CNS/medullary paralysis

95
List the physiological effects of nicotine in the PNS.
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↑ BP, HR, cardiac contractility smooth muscle contraction causes vasoconstriction increases metabolism rate of medications

96
What are the withdrawal symptoms of nicotine?
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Cravings, irritability, restlessness, difficulty concentrating, anxiety, excessive hunger, and sleep disturbance.

97
How long after quitting do withdrawal symptoms typically start?
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Within a few hours from the last cigarette.

98
When are withdrawal symptoms the strongest?
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2-3 days after quitting

99
Forms of nicotine replacement therapy
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Patch, gum, lozenge, nasal spray

100
Medications that act on nicotinic receptors?
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Bupropion, Varenicline

101
MOA of Bupropion
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Dopamine-norepinephrine reuptake inhibitor

102
What is the MOA of Varenicline?
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Nicotine receptor partial agonist