Texas Physician Ebook Continuing Education

This interactive Texas Physician Ebook contains 23 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.

Texas Continuing Medical Education

2024 Texas Medical Licensure Program




INCLUDES: DEA’s new one-time MATE requirement





InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

2024 TEXAS




BEST PRACTICES FOR TREATING PAIN WITH OPIOID ANALGESICS COURSE THREE | 2 CREDITS+ +This course satisfies the Pain Management/Prescription of Opioids and Medical Ethics requirement COURSE TWO | 1 CREDIT** **This HHSC Approved course satisfies the Human Trafficking Training requirement RECOGNIZING AND RESPONDING TO HUMAN TRAFFICKING IN TEXAS






*+ In addition to satisfying the Human Trafficking and Pain Management/Opioids requirements, these formal hours may be credited towards the requirement for Medical Ethics and/or Professional Responsibility for any physician.

Program Options


23 Credits


15 Credits



8 Credits


3 Credits

CME that counts for MOC Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities (see page iii for further details). InforMed currently reports to the following specialty boards: the American Board of Internal Medicine (ABIM), the American Board of Anesthesiology (ABA), the American Board of Pediatrics (ABP), the American Board of Otolaryngology–Head and Neck Surgery (ABOHNS), and the American Board of Pathology (ABPath). To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting. DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.

InforMed has joined the Elite Learning family Two of the nation’s top healthcare education providers have joined forces with one goal in mind: to offer physicians a state-of-the-art learning experience that fulfills your state requirements and empowers you with the knowledge you need to provide the best patient care. Here’s what you can expect from our new partnership: • COURSES: In addition to the mandatory courses you need to renew your state license, you’ll now have access to dozens of hours of elective courses and an expanded content library. • ACCOUNTS: You’ll also have access to a personalized learner account. In your account you can add, organize, and track your ongoing and completed courses. For instructions on how to set up your account, email us at office@elitelearning.com. • BOOK CODES: You may notice a book code on the back cover of the latest InforMed program you’ve received in the mail. When entered on our new site, this code will take you directly to the corresponding self-assessment. See more information below. How to complete Please read these instructions before proceeding.

Read and study the enclosed courses and answer the self-assessment questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer three ways for you to complete. Choose an option below to receive credit and your certificate of completion. Scan this QR code to complete your CE now !

Fastest way to receive your certificate of completion


• Go to BOOK.CME.EDU . Locate the book code TX24CME found on the back of your book and enter it in the box then click GO . If you would like to choose a different program option, use the table below and enter the corresponding code in the box. • If you already have an account created, sign in to your account with your username and password. If you do not have an account already created, you will need to create one now. • Follow the online instructions to complete your self-assessment. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.

Enter book code


Example: TX24CME

If you need help finding your code, Browse Book Code FAQs

Program Options




Entire Program




Courses 2, 3 and 4

TX24CME-95 15


Course 1

TX24CME-801 8


Courses 2 and 3

TX24CME-501 3


By mail

By fax

• Fill out the answer sheet and evaluation found in the back of this booklet. Please include a check or credit card information and e-mail address. Mail to InforMed, PO Box 2595, Ormond Beach, FL 32175-2595 . • Completions will be processed within 2 business days from the date it is received and certificates will be e-mailed to the address provided.

• Fill out the answer sheet and evaluation found in the back of this booklet. Please include credit card information and e-mail address. Fax to 1-800-647-1356 . • All completions will be processed within 2 business days of receipt and certificates will be e-mailed to the address provided.

• Submissions without a valid e-mail will be mailed to the address provided.

• Submissions without a valid e-mail will be mailed to the address provided.






Texas Professional License Requirements


CONTINUING MEDICAL EDUCATION REQUIREMENT Physicians (MD/DO) need to complete at least 48 hours of continuing medical education every 24 months (24 month timeline is in relation to the biennial registration period, not the calendar year). At least 24 of these hours must be in formal courses (AMA Category 1 or equivalent). PAIN MANAGEMENT AND THE PRESCRIPTION OF OPIOIDS REQUIREMENT Per Texas Administrative Code Title 22, Part 9, Chapter 166 for licensed physicians (MD/DO) and Chapter 185 for licensed physician assistants (PA), at least two (2) of the formal hours required must involve the study of the following topics: best practices, alternative treatment options, and multi-modal approaches to pain management that may include physical therapy, psychotherapy, and other treatments; safe and effective pain management related to the prescription of opioids and other controlled substances, including education regarding standards of care, identification of drug-seeking behavior in patients, and effectively communicating with patients regarding the prescription of an opioid or other controlled substances; and prescribing and monitoring of controlled substances. These formal hours may be credited towards the requirements for medical ethics or professional responsibility for any physician. HUMAN TRAFFICKING TRAINING REQUIREMENT Per Texas Occupations Code, Title 3, Subtitle B, Sec. 156.060, licensed physicians (MD/DO) and physician assistants (PA) are required to complete a human trafficking prevention course approved by the Texas Health and Human Services Commission (HHSC). These formal hours may be credited towards the requirements for medical ethics or professional responsibility for any physician. DEA ONE-TIME MATE REQUIREMENT (NEW) Effective June 27, 2023 , renewing DEA-registered practitioners must complete eight (8) hours of one-time training on the treatment and management of patients with opioid or substance use disorders.

We are a nationally accredited CME provider. For all board-related inquiries please contact:

Texas Medical Board 333 Guadalupe Tower 3, Suite 610 Austin, TX 78701 P: (512) 305-7010



Disclaimer: The above information is provided by InforMed and is intended to summarize state CE/CME license requirements for informational purposes only. This is not intended as a comprehensive statement of the law on this topic, nor to be relied upon as authoritative. All information should be veri ed independently.



In addition to awarding AMA PRA Category 1 Credits TM , the successful completion of enclosed activities may award the following MOC points and credit types. To be awarded MOC points, you must obtain a passing score and complete the corresponding activity evaluation.

Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs ABA American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®


American Board of Internal Medicine’s Maintenance of Certification (MOC) program

ABOHNS American Board of Otolaryngology – Head and Neck Surgery’s Continuing Certification program (formerly known as MOC)


American Board of Pathology’s Continuing Certification Program


American Board of Pediatrics’ Maintenance of Certification (MOC) program.

Table 2. Credits and Type Awarded

AMA PRA Category 1 Credits TM 8 AMA PRA Category 1 Credits TM 1 AMA PRA Category 1 Credit TM 2 AMA PRA Category 1 Credits TM

Activity Title



Substance Use Disorders: A DEA Requirement Recognizing and Responding to Human Trafficking in Texas Best Practices for Treating Pain with Opioid Analgesics Existing & Emerging Patient Safety Practices

8 Credits LL 1 Credit LL 2 Credits LL 12 Credits LL & PS

8 Credits MK 1 Credit MK 2 Credits MK 12 Credits MK & PS

8 Credits SA

8 Credits LL 8 Credits LL+SA

1 Credit SA 1 Credit LL

1 Credit LL+SA

2 Credits SA 12 Credits SA & PS

2 Credits LL 2 Credits LL + SA

12 AMA PRA Category 1 Credits TM 12 Credits LL 12 Credits LL+SA Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, , LL+SA = Lifelong Learning & Self- Assessment, PS = Patient Safety

Table 3. CME for MIPS Statement Completion of each accredited CME activity meets the expectations of an Accredited Safety or Quality Improvement Program (IA PSPA_28) for the Merit-based Incentive Payment Program (MIPS). Participation in this Clinical Practice Improvement Activity (CPIA) is optional for eligible providers.






Release Date: 5/2023 Exp. Date: 5/2026

8 AMA PRA Category 1 Credits ™

Enduring Material (Self Study)

TARGET AUDIENCE This course is designed for all physicians.


• Read the course materials.

• Complete the self-assessment questions at the end. A score of 70% is required. • Ret urn your customer information/ answer sheet, evaluation, and payment to InforMed by mail, phone, fax or complete online at program website.

COURSE OBJECTIVE The purpose of this course is to provide information on substance use disorders of controlled and non-controlled substances, as well as review select controlled substance topics.

Completion of this course will better enable the course participant to: 1. Discuss substance use disorders. 2. Describe the roles of the DEA, FDA, and HHS in scheduling-controlled substances and enforcing controlled substance laws and regulations. 3. Understand the different DEA Controlled Substance Schedules and prescribing regulations associated with the different DEA Controlled Substance Schedules. 4. Review medical marijuana legislation. 5. Describe essential considerations when prescribing controlled substances, including regulatory exceptions and clinical concerns. 6. Describe controlled substance prescribing practices. 7. Understand the treatment options for patients suffering from Substance Use Disorder (SUD). LEARNING OBJECTIVES IMPLICIT BIAS IN HEALTHCARE Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.

ACCREDITATION STATEMENT InforMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.


DESIGNATION STATEMENT InforMed designates this enduring material for a maximum of 8 AMA PRA Category 1 Credits ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Substance Use Disorders: A DEA Requirement 8 COURSE SATISFIES

FACULTY Brad Bendesky, MD FACEP, FAAEM Chair, Department of Emergency Medicine Mercy Catholic Medical Center-Mercy Fitzgerald Hospital Associate Professor of Clinical Emergency Medicine Drexel College of Medicine, Philadelphia PA Humberto Reinoso, PhD, FNP-BC, ENP-BC Assistant Professor Nurse Practitioner Coordinator Georgia Baptist College of Nursing of Mercer University Robyn B. Caldwell DNP, FNP-BC, PMHNP Medical Writer

This course satisfies eight (8) hours on the DEA’s new one-time MATE requirement.

Effective June 27, 2023, renewing DEA-registered practitioners must complete 8 hours of one-time training on the treatment and management of patients with opioid or substance use disorders.


In accordance with the ACCME Standards for Commercial Support of CME, InforMed implemented mechanisms, prior to the planning and implementation of this CME activity, to identify and resolve conflicts of interest for all individuals in a position to control content of this CME activity. FACULTY/PLANNING COMMITTEE DISCLOSURE The following faculty and/or planning committee members have indicated they have no relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients: • Brad Bendesky, MD • Humberto Reinoso, PhD, FNP-BC, ENP-BC • Robyn B. Caldwell DNP, FNP-BC, PMHNP STAFF AND CONTENT REVIEWERS InforMed staff, input committee and all content validation reviewers involved with this activity have reported no relevant financial relationships with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. DISCLAIMER *2023. All rights reserved. These materials, except those in the public domain, may not be reproduced without permission from InforMed. This publication is designed to provide general information prepared by professionals in regard to the subject matter covered. It is provided with the understanding that InforMed, Inc is not engaged in rendering legal, medical or other professional services. Although prepared by professionals, this publication should not be utilized as a substitute for professional services in specific situations. If legal advice, medical advice or other expert assistance is required, the service of a professional should be sought.


All substances activate the same brain reward pathway via dopaminergic neurotransmission. 5 Individuals who demonstrate a chronic loss of control or compulsive use of substances along with a wide range of negative effects (mental, physical, and social well-being) meet the criteria for substance related disorders. 3 Standardized screening is important to determine the stage of substance use, consequences, and functional impairment. 5 Controlled Substance Act (CSA) The Comprehensive Drug Abuse Prevention and Control Act of 1970 , or the Controlled Substance Act (CSA), regulates pharmaceutical and illicit controlled substances in the United States 2010 Statement of Policy: Role of Authorized Agents in Communicating Controlled Substance Prescriptions to Pharmacies. 6 The CSA requires registration, outlines specific rules about dispensing pharmaceutical controlled substances, and determines the legality of these substances. The U.S. Drug Enforcement Agency (DEA) was formed in 1973 to enforce the CSA. For pharmaceutical controlled substances, the DEA is responsible for preventing the diversion and abuse of controlled drug substances. The agency also ensures that an adequate and uninterrupted supply of pharmaceutical controlled substances is available to meet legitimate medical, scientific, and research needs. Along with state and other federal agencies, the DEA regulates the registration of manufacturers, distributors, and dispensers of controlled pharmaceutical substances and the import and export of these substances. The DEA prosecutes anyone who violates this law. 7 The U.S. federal agencies involved in scheduling controlled substances include the Drug Enforcement Agency (DEA), Food and Drug Administration (FDA), and Department of Health and Human Services (HHS). Drugs and other substances that are considered controlled substances under the CSA are divided into five schedules. Substances are placed in their respective schedules based on whether they have a currently accepted medical use in treatment in the United States, their relative abuse potential, and the likelihood of causing dependence when abused. • Schedule I Controlled Substances.

Schedule IV Controlled Substances. Substances in this schedule have a low potential for abuse relative to substances in Schedule III. Schedule V Controlled Substances. Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics. Neurobiology of Substance Use Disorders

Substance-Related Disorders Substance use disorders are a significant public health problem with a wide range of negative effects on individuals’ mental, physical, and social well-being. Mental health problems co-occurring with substance use disorders include depressive, anxiety, and psychotic disorders, as well as organic brain syndromes. 2 Substance use disorders share many of the same features but differ in pharmacology and associated behaviors that account for the unique effects of each substance. 3 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision , often called the DSM-V-TR or DSM-5-TR, is the latest version of the American Psychiatric Association’s publication defining various conditions. 4 The DSM-5-TR recognizes substance-related disorders resulting from the use of 10 separate classes of substance including the following: • Alcohol • Caffeine • Cannabis • Hallucinogens • Inhalants • Opioids • Sedatives • Hypnotics or anxiolytics • Stimulants (including amphetamine-type substances, cocaine, and other stimulants) • Tobacco The criteria used to diagnose and define substance use disorders spans a wide variety of problems arising from substance use, and they include the following: 1. Taking the substance in larger amounts or for longer than meant to 2. Wanting to cut down or stop using the substance but not managing to 3. Spending a lot of time getting, using, or recovering from use of the substance 4. Cravings and urges to use the substance 5. Not managing responsibilities at work, home, or school because of substance use 6. Continued use, even when it causes problems in relationships 7. Giving up important social, occupational, or recreational activities because of substance use 8. Using substances repeatedly, even after negative outcomes 9. Continued use, even when physical or psychological problem have been caused or complicated by the substance 10. Seeking more of the substance to get the effect you want (tolerance) 11. Development of withdrawal symptoms that are relieved by taking more of the substance The hallmark of substance use disorders includes cognitive, behavioral, and physiological symptoms of intoxication, withdrawal, and dependence. 4 Diagnosis is based on pathological patterns of substance use.

Substance use disorders (SUDs) are complicated physiologic and psychological disorders with multiple intersecting factors, such as drug use behaviors and poor judgment influenced by the pharmacodynamics and pharmacokinetic actions of the drug. The central element of drug dependence is the drug-using behavior. Drug use initiates a cascade of rewarding or aversive physical, psychological, and social consequences that determine the likelihood of subsequent use. 8 The development and persistence of SUDs are largely based on key components within the basal ganglia, amygdala (extended), and prefrontal cortex. The basal ganglia and its sub-networks are responsible for reward, pleasure, and formation of habitual substance use. 9 The amygdala is responsible for the uneasy feelings, anxiety, and irritability associated with withdrawal. The prefrontal cortex is involved in executive function and exerts control over the individual’s cognitive inability to reject substance use based on neurocircuitry, namely impulsivity and compulsivity. 10 These endophenotypes are found transdiagnostically across many psychopathologies. Impulsivity, when characterized as the failure to resist a drive or impulse potentially harmful to the self or others, is a core feature of several psychiatric disorders, including substance use disorder. 11 Impulsivity causes the individual to act without forethought, unable to reflect on previous behavior and seek immediate reward by choosing risky behavior. Compulsivity is characterized by inappropriate actions which persist regardless of the situation. Over time, impulsive substance use becomes compulsive addiction as this dysregulation becomes a dependent conditioned response. The impulses in the ventral loop of reward and motivation migrate dorsally because of neuroplasticity and engage in a habit system, creating the conditioned response of addiction. 12 Impulsive drug use produces a high , which if experienced too often causes the migration to compulsive use (addiction) to reduce the unpleasant effects of withdrawal. The mesolimbic pathway is hypothesized to be the final common pathway of reward and reinforcement in the brain, where all addictive drugs increase dopamine, especially with habitual use. 13 Arising in the ventral tegmental area (VTA), it projects into the nucleus accumbens (NA) and prefrontal cortex (PFC).

Substances in this schedule have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse. Schedule II/IIN Controlled Substances (2/2N). Substances in this schedule have a high potential for abuse, which may lead to severe psychological or physical dependence. Schedule III/IIIN Controlled Substances (3/3N). Substances in this schedule have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.


Apart from the LSD- and mescaline-like hallucinogens, functional dopamine agonism is the single pharmacological property that all addictive drugs share. 14 The psychology of substance use disorders reflects psychodynamic theories dating back 100 years. Disturbed ego functions, self-medication, and alexithymia (inability to describe feelings) are common among those with substance use. Aside from pharmacologic effects, positive reinforcement is gained from paraphernalia and associated behaviors with drug use. Conditioned responses (similar to Pavlovian phenomena) such as cravings and withdrawal promote relapsing behaviors. Individuals aged 18–24 years have a high prevalence rate for virtually every substance disorder. 15 Implicit Bias and Stigma in Substance Use Disorders Language used by clinicians such as addict can stigmatize individuals with substance use disorders, reflecting misconceptions that these behaviors are choices rather than compulsions. Negative biases can dehumanize individuals, affecting the therapeutic alliance and ultimately the course of recovery. Clinicians who stereotype drug use as a criminal activity marginalize disadvantaged groups and negatively influence treatment plans, which may increase drug use. Fear about disclosing substance use, decreased quality of care, or reduced access to care are impacted by stigma and implicit biases. 16 To this end, the word addiction has been eliminated from the DSM-5 in favor of the more neutral term substance use disorder. 4 Every member of our community may help to lessen stigma and prejudice against those who suffer from drug use disorders by: • Understanding substance use disorders are chronic, treatable medical conditions. • Changing stigmatizing language with more empowering, preferred language that doesn’t equate people with their condition or have negative connotations. • Addressing systemic racism, sexism, and other forms of discrimination, which leads to multiple layers of stigma for many people with addiction. 17 Risk Factors for Substance Use Disorders Risk factors influence a young individual’s likelihood of developing SUD. Some of the risk factors are as follows 18 : • Family history of substance use • Favorable parental attitudes toward the behavior • Poor parental monitoring • Parental substance use • Family rejection of sexual orientation or gender identity • Association with delinquent or substance- using peers

• Childhood sexual abuse • Mental health issues Other risk factors include 19 : • Avoidant coping style • Bereavement • Chronic pain or physical illness/comorbidity • Significant stressful life changes • Social isolation Individuals who demonstrate a chronic loss of control or compulsive use of substances along with a wide range of negative effects (mental, physical, and social well-being) meet the criteria for substance related disorders. 8 Standardized screening is important to determine the stage of substance use, consequences, and functional impairment. 5 The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. To facilitate understanding of the risks of SUD, SAMHSA developed the Strategic Prevention Framework (SPF). The five steps and two guiding principles of the SPF offer prevention planners a comprehensive approach to understanding and addressing the substance misuse and related behavioral health problems facing their states and communities. The SPF includes these five steps 20 : 1. Assessment: Identify local prevention needs based on data (e.g., What is the problem?). 2. Capacity: Build local resources and readiness to address prevention needs (e.g., What do you have to work with?). 3. Planning: Find out what works to address prevention needs and how to do it well (e.g., What should you do and how should you do it?). 4. Implementation: Deliver evidence-based programs and practices as intended (e.g., How can you put your plan into action?). 5. Evaluation: Examine the process and outcomes of programs and practices (e.g., Is your plan succeeding?). The SPF is also guided by two cross-cutting principles that should be integrated into each of the steps that comprise it: 1. Cultural competence. The ability of an individual or organization to understand and interact effectively with people who have different values, lifestyles, and traditions based on their distinctive heritage and social relationships. 2. Sustainability. The process of building an adaptive and effective system that achieves and maintains desired long-term results. Alcohol Use Disorder Alcohol addiction is a chronic relapsing disorder associated with compulsive drinking. Alcohol use is a common disorder that is defined by a cluster of behavioral and physical symptoms and can include withdrawal, tolerance, and craving.

Approximately 69.5% of those ages 18 and older reported drinking alcohol in the past year, with 59.4% admitting to drinking alcohol in the last month. 21 Severity of alcohol use disorder is based on the number of diagnostic criteria in a given individual, along with changes in severity of alcohol use across time, reflected by reductions in the frequency of alcohol consumed. Alcohol use disorder has a variable course characterized by remissions and relapses. Alcohol use disorder is associated with increased risks of accidents and injury, violence, and suicide. Severe alcohol use is associated with comorbid conditions such as depression or other disinhibitions of feelings, which contribute to suicide attempts as well as completed suicides. 4 Other disorders associated with alcohol use disorders include psychosis, bipolar disorders, anxiety disorders, sleep disorders, and neurocognitive disorders. Long-term alcohol use can also cause complications in almost every physiologic system. Addiction Cycle in Alcohol Use Disorder Alcohol consumption is linked to health and social consequences interfering in personal relationships, frequent medical complications including cancer, motor vehicle collisions, and violence. The powerful effects on the brain account for euphoria and pleasurable feelings, increasing the motivation to use these substances despite the risk of harm. The addiction cycle is based on three concepts: (1) binge/intoxication, (2) withdrawal/negative effects, and (3) preoccupation/anticipation. An individual may experience all stages in the course of a day or over weeks or months. 21 1. Binge/intoxication stage is a stage where an individual experiences the rewards including euphoria, anxiety reduction, and easing of social interactions. Repeat activation of the basal ganglia reinforces the likelihood of repeated consumption through motivation and routine behaviors. The repeated activation of the basal ganglia changes the way an individual responds to stimuli, which then triggers powerful urges to consume the substance over time. 2. Negative affect/withdrawal stage occurs when an individual stops drinking and withdrawal symptoms occur. These symptoms can be physical (sleep disturbances, pain, and ill feelings) or emotional (dysphoria, irritability, anxiety, and emotional pain). Negative feelings associated with alcohol withdrawal come from two sources. Diminished activation in the reward system makes it difficult to experience the euphoria associated with everyday living. Increased activation of brain stress contributes to anxiety, irritability, and unease. The individual consumes alcohol to escape the lows of chronic alcohol use. stage occurs when an individual seeks alcohol after a period of abstinence. This stage can be triggered by various factors such as stress, social situations, or environmental associated with previous substance use. 3. Preoccupation/anticipation

• Lack of school connectedness • Low academic achievement


These triggers can create a psychological and physiological response in the brain, leading to a strong urge to use alcohol. The prefrontal cortex, responsible for executive function, is compromised in alcohol use disorder. 133 Alcohol Intoxication Alcohol intoxication usually develops over minutes to hours and lasts about several hours. The first episode of alcohol intoxication most commonly occurs in the mid-teens, but alcohol use disorder is not typically identified in late teens or early 20s. The essential feature of alcohol intoxication is the presence of behavioral or psychological changes, including inappropriate sexual or aggressive behavior, mood lability, impaired judgment, and levels of incoordination that may interfere with the performance of usual activities. The degree of intoxication increases with the blood alcohol concentration, especially when combined with other sedation-producing substances. 4 Table 1. Blooad Alcohol Concentrations (BAC) with Impairment 20-30 mg/dL Slowed motor impairment with decreased thinking ability 30-80 mg/dL Increased motor and cognitive problems 80-200 mg/dL Incoordination and judgment errors with deterioration in cognition 200-300 mg/ dL Nystagmus, slurred speech, and blackouts >300 mg/dL Impaired vital signs and possible death If an individual lacks significant impairment at 150 mg/dL, pharmacodynamic tolerance may be present. 23 However, an individual’s history of regular exposure to alcohol dictates the behavior that follows its consumption since the human body and the central nervous system can develop tremendous tolerance to ethanol. Mental and physical dysfunctions from ethanol, in an alcohol- tolerant individual, do not consistently correlate with ethanol levels traditionally used to define intoxication, or even lethality, in a nontolerant subject. 22 Alcohol Withdrawal Alcohol withdrawal can occur with anyone with alcohol use disorder and symptoms can range from mild to severe and occasionally life threatening. Minor symptoms include anxiety, tremor, diaphoresis, palpitations, nausea and vomiting. The symptoms can be progressive and severe, eventually leading to seizures and autonomic hyperactivity. The classic sign of alcohol withdrawal is tremulousness. 23 Alcohol withdrawal seizures typically occur within 6-48 hours after cessation of drinking in a habituated alcohol drinker and occur in 10-30 percent of patients in alcohol withdrawal. Alcohol withdrawal can produce generalized tonic clonic seizures, but status epilepticus is rare. 23

The estimated progression of alcohol withdrawal symptoms is presented in Table 2. 23 Evaluation of the severity of withdrawal includes physical examination and the use of the CIWA score. The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale has 10 items, each evaluated independently and then aggregated to yield a score correlating with severity of alcohol withdrawal. 23 The CIWA-AR score requires evaluation of each symptom rated on a 0-7 score for all except evaluation of orientation and clouding of sensorium, which is on a 0-4 score. Maximum score is 67:

Hospital protocols vary, but admission to monitored or intensive care settings is warranted for significant withdrawal symptoms. Complications of Chronic Alcohol Use Chronic alcohol use is associated with many conditions. Alcohol is characterized as a Group 1 carcinogen along with tobacco, radiation, and asbestos. It is associated with bowel and breast cancer and although previously thought to be safe in light and moderate consumption, the World Health Organization (WHO) has now published a statement in The Lancet Public Health that when it comes to alcohol consumption, there is no safe amount of alcohol that does not affect health. 27 Chronic alcohol use is commonly associated with many health issues as follows: • Gastrointestinal: hepatic steatosis, hepatitis and cirrhosis, gastritis, and ulcer disease leading to GI bleeding and pancreatitis • Cardiac: cardiomyopathies, hypertension, heart failure, and arrhythmias leading to stroke • Metabolic: electrolyte derangements, including hypoglycemia and hyponatremia and hypomagnesemia, thrombocytopenia, osteopenia, folate and thiamine deficiencies • Genitourinary: chronic alcohol use contributes to erectile dysfunction and dysfunctional uterine bleeding • Immunologic: increased risk of infection through effects on lymphocyte response • Long term alcohol use associated with increased frequency of many malignancies • Psychologic: depression and anxiety • Increased risk of injury due to dangerous behavior Wernicke-Korsakoff syndrome (WKS) is one of the best-known neurologic complications of thiamine (vitamin B1) deficiency that is frequently associated with long-term alcohol use. Thiamine is involved in the conduction of axon potential and synaptic transmission. WKS refers to two different syndromes, each representing a different stage of the disease. Wernicke encephalopathy (WE) is an acute syndrome requiring emergent treatment to prevent death and neurologic morbidity. Korsakoff syndrome (KS) refers to a chronic neurologic condition that usually occurs as a consequence of WE. Wernicke encephalopathy (alcoholic encephalopathy) is characterized by ataxic gait, vestibular dysfunction, confusion, horizontal nystagmus, lateral orbital palsy, and gaze palsy. WE is reversible with acute treatment including replacement of thiamine and other deficient vitamins such as folic acid.

• Agitation (0-7) • Anxiety (0-7)

• Auditory disturbances (0-7) • Clouding of sensorium (0-4) • Headache (0-7)

• Nausea/vomiting (0-7) • Paroxysmal sweats (0-7) • Tactile disturbances (0-7) • Tremor (0-7) • Visual disturbances (0-7) Scores correlate to general level of withdrawal as follows:


Withdrawal Level


Absent or minimal withdrawal Mild to moderate withdrawal

9-19 ≥20

Severe withdrawal

Delirium Withdrawal delirium, also commonly referred to delirium tremens or “DTs,” is the most dangerous withdrawal syndrome associated with alcohol. This spectrum of symptoms that includes confusion, disorientation, hallucinations, and delusions along with autonomic hyperactivity, anxiety, and fluctuating levels of psychomotor activity has a modern mortality of under 5% if treated as opposed to mortality rates greater than 25% early in the 20th century. 24 Withdrawal delirium typically begins between 72 and 96 hours after the patient’s last drink and has been reported to occur in 1 to 4 percent of patients hospitalized for alcohol withdrawal. 25 Delirium tremens should be considered a medical emergency and can be fatal if not managed aggressively. The main objectives of treatment for alcohol withdrawal are controlling agitation, lowering seizure risk, and reducing morbidity and mortality. Benzodiazepines such as diazepam and lorazepam are first-line treatment for all alcohol withdrawals. Barbiturates and propofol can be used for those patients who are refractory to benzodiazepines. 26

Table 2. Alcohol Withdrawal Progression



Time to Presentation



6-8 hours 8-12 hours 12-24 hours


Perceptual disturbances



Life threatening

Delirium tremens

Within 72 hours


Korsakoff syndrome is a chronic amnestic syndrome which follows Wernicke encephalopathy in which the main feature is anterograde amnesia, with possible confabulation. If left untreated, thiamine deficiency can eventually lead to neuronal death, and lesions can be identified on radiographic imaging and autopsy. 28 Vitamin deficiencies must be considered during the evaluation and treatment of all patients with a history of chronic alcohol use. Antidipsotropic Medications for Treatment of Alcohol Use Disorder Acamprosate appears to be one of the most effective medications for maintaining abstinence in alcohol use disorder. Acamprosate is thought to target GABA and N-methyl-D-aspartate glutamatergic receptor activity, thereby decreasing cravings and relapse. The individual must be alcohol free at initiation, and use is contraindicated in severe renal disease. Side effects include diarrhea and nausea. Dosing is weight based, and titration is not required. 29 Disulfiram is a second-line treatment to treat individuals who are dependent on alcohol but are motivated to discontinue use. Alcohol consumption results in increased serum acetaldehyde causing diaphoresis, palpitations, facial flushing, nausea, vertigo, hypotension, and tachycardia.

These symptoms are known as disulfiram-alcohol reaction and discourage alcohol intake. Side effects include headache, skin rash, drowsiness, and metallic aftertaste; adverse reactions include hepatitis and peripheral neuropathy. 30 Naltrexone is considered first-line therapy for individuals with moderate or severe AUD and is an option for treatment of both alcohol and opioid dependence by the action of blocking the mu- receptor. Additionally, naltrexone also modifies the hypothalamic-pituitary-adrenal axis to suppress alcohol consumption. 31 It is prescribed in both oral and long-acting injectable forms. The therapeutic action of opioid receptor antagonism is to blunt the rewarding effects of alcohol. Side effects include mild nausea and vomiting and dizziness. Studies have supported doses of 50 mg/day of naltrexone significantly decreased the likelihood of a return to heavy drinking and, in some cases, resulted in abstinence. 32 Off-label use of topiramate, gabapentin, and baclofen has also assisted in treatment of AUD. Cognitive behavioral therapy (CBT) approaches have among the highest level of empirical support for the treatment of alcohol use disorders and show a small but statistically significant treatment effect over controls. 33

BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 1. Sedatives, Hypnotics, and Anxiolytics Sedative, hypnotic, or anxiolytic use disorder is a substance use disorder characterized by repeated use of substances including benzodiazepines, benzodiazepine-like drugs (e.g., zolpidem, zaleplon), carbamates (e.g., glutethimide, meprobamate), barbiturates (e.g., phenobarbital, secobarbital), and barbiturate- like hypnotics (e.g., glutethimide, methaqualone) despite significant problems associated with their use. This class also includes all prescription sleeping medications and most prescription antianxiety medications. Nonbenzodiazepine antianxiety agents (e.g., buspirone, gepirone) are not typically included in this class because they are not associated with significant misuse. Anxiolytics are a class of medications aimed at treating patients with anxiety and panic disorders, but they have various other uses. Sedatives (hypnotics) are a class of drugs used in different situations ranging from treating insomnia to sedation for painful procedures.

Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow. Case Study 1

Mrs. Smith accompanies her husband Mr. Smith to an office visit to discuss some symptoms that she has recently noticed. During the interview Mrs. Smith admits to at least 1-2 glasses of wine each night; she uses this to help her relax and occasionally uses additional glasses to help her get to sleep. Recently, she expressed a desire to cut down on this habit but has had difficulty doing so. This habit is creating tension in their relationship, and Mr. Smith describes a few instances where Mrs. Smith has appeared shaky after attempting to abstain from alcohol use. She has sustained some minor injuries in the past due to falls after drinking alcohol. They are both seeking guidance on how to proceed.

1. Does Mrs. Smith meet any criteria for substance use disorder?

2. What therapies would be appropriate for treatment?

Mrs. Smith is brought back to see the physician by her husband and is now very anxious and nauseated. Her blood pressure is 175/95, her pulse is 125, and her respiratory rate is 22. She is diaphoretic and tremulous. She states that she continues to abstain from alcohol but now has a headache. Mr. Smith states she is more tremulous than before and is worried about what to do.

3. Are there clinical tools to guide you on the severity of her condition?

4. You calculate a CIWA score and find that Mrs. Smith has a CIWA score of 12. Do you think that Mrs. Smith should be referred to the hospital?


Both of these classes of medications have broad uses in various conditions and are effective when used at proper dosages and under the guidance of trained medical professionals. However, these drugs also run a high risk of misuse and abuse and frequently lead to untoward consequences. Benzodiazepines (BZDs) are among the most commonly prescribed psychoactive drugs by clinicians in primary care. 34 Individuals with sedative, hypnotic, or anxiolytic use disorders are frequently treated in the outpatient setting. BZDs are Food and Drug Administration (FDA) indicated for a number of conditions such as anxiety disorders, insomnia, acute status epilepticus, induction of amnesia, spastic disorders, and agitation. Non-FDA-approved indications include Tourette’s syndrome, delirium, delirium tremens, sleep disorders, and abnormal movements associated with other medications. 37 Sedative drugs decrease activity, diminish excitement, and calm the individual. Sedatives are often used to alleviate unwanted side effects of other substances. Hypnotic drugs produce drowsiness and facilitate the onset and maintenance of a state of sleep that resembles natural sleep in its electroencephalographic characteristics and from which the recipient can be easily aroused. 35 These medications have varying mechanisms of action but generally exert their most significant effect on the central nervous system. They act by facilitating the binding of the inhibitory neurotransmitter GABA at various GABA receptors throughout the CNS. 36 Nonbenzodiazepines including zolpidem, zaleplon, and eszopiclone, referred to as Z-drugs, were developed as alternatives to BZDs and have clinical effects similar to BZDs but may be more prone to misuse and dependence. Anxiolytics or sedative-hypnotic drugs can be viewed on a continuum based on sedating properties of the class. Physical and psychological dependence does occur, and all have withdrawal symptoms. Alcohol take along with drugs in this class has additive effects. The essential features of this drug class are maladaptive behavioral or psychological changes. In some, memory impairment causes anterograde amnesia similar to blackouts .

BZDs are contraindicated in angle-closure glaucoma and have a black box warning with concomitant use with opioids, which lead to severe respiratory depression, coma, and death. However, in a supervised setting, BZDs can be used to quell the significant anxiety associated with stimulant intoxication and opioid withdrawal. Several groups are at high risk for abuse, and caution is essential when prescribing BZDs. Individuals who consume large amounts of alcohol often present for treatment of anxiety and insomnia, and there is an elevated likelihood of abuse of this class of drug. Individuals may self-medicate for insomnia, anxiety, and withdrawal. Additionally, benzodiazepines increase the hedonistic effects of methadone. 39 Older individuals are at unique risk of significant cognitive impairment while using benzodiazepines, which may lead to gait disturbances and sedation causing injury. A risk versus benefit analysis must be calculated when deciding to use BZDs in clinical scenarios. Sedative, Hypnotic, or Anxiolytic Intoxication Relatively low doses of sedatives, hypnotics, or anxiolytics can lead to intoxication during or shortly after use. Patients should be monitored closely for signs of intoxication, which include the following: • Drowsiness or sedation Treatment of acute sedative intoxication and overdose is primarily supportive and requires close monitoring of hemodynamic and respiratory status and observation until the drug is fully metabolized. A reversal agent exists. Flumazenil is a benzodiazepine antagonist. It competitively inhibits the activity of benzodiazepine and nonbenzodiazepine substances that interact with benzodiazepine receptors site on the GABA/ benzodiazepine receptor complex. It must be used with extreme caution to prevent acute precipitated withdrawal in the patient with sedative habituation. Complications may include intractable seizures. The use of flumazenil should be limited to those clinicians with familiarity with the drug. • Slurred speech • Incoordination • Unsteady gait • Nystagmus • Impaired cognition • Stupor or coma

Sedative, Hypnotic, and Anxiolytic Withdrawal The severity of withdrawal varies with dose and duration; however, it can occur with short- term, relatively low dose use of BZDs. Withdrawal symptoms include: • Autonomic hyperactivity (diaphoresis, tachycardia) • Hand tremors • Insomnia • Nausea/vomiting • Transient visual, tactile, or auditory hallucinations • Psychomotor agitation • Anxiety • Grand mal seizures Deprescribing BZDs is an important clinical skill, and the first goal of treatment in detoxification. Certain individuals may not require long-term BZDs. When deprescribing BZDs, consider duration of treatment, dose, and half-life of the BZD. Consider a taper over several weeks or months. Often switching to a long-acting BZD is an effective method in an individual who has serious abuse problems. Tapering is effective in cases of long-acting benzodiazepines but is not as effective in short- acting benzodiazepines. For example, an individual who has been taking a BZD for 12 weeks should be monitored closely while implementing a reduction of 10-25% of the dose per week. 40 Sedative Use Disorder Treatment No standard exists for determination of the appropriateness of inpatient versus outpatient settings for the management of patients who are suffering withdrawal symptoms or who are attempting to manage their long-term sedative use. Tapering doses of benzodiazepines can be managed effectively in the outpatient setting in stable healthy patients using the strategies discussed earlier. Substitution of a long-acting benzodiazepine such as Clonazepam for a short-acting drug such as Valium would eliminate the associated euphoria and illicit market value of the medication and may assist in detoxification and inappropriate use. Acute withdrawal that may be associated with delirium, abnormal vital signs, seizures, or patients with multiple comorbidities that may be at risk from labile vital signs during the withdrawal period would be more appropriately managed in a supervised inpatient setting. 145 Stimulant-Related Disorders Stimulant use disorders include a range of issues related to illicit cocaine, methamphetamine, and ecstasy, as well as prescription stimulants that include methylphenidate and amphetamine. The general mechanism of stimulants revolves around increased catecholamine levels and increased agonistic activity at adrenergic receptors. Acute adverse effects can cause acute conditions including tachycardia, vasoconstriction, and bronchodilation, as well as hyperthermia.

Table 3. FDA Approved Benzodiazepines 38



Common Indication



Anxiety, panic disorders, agoraphobia


Librium Alcohol withdrawal syndrome

Clonazepam Quazepam Temazepam Diazepam Lorazepam

Klonopin Panic disorder and agoraphobia; myoclonic and absence seizures


Chronic insomnia


Onset and sleep maintenance in insomnia

Valium Alcohol withdrawal management

Ativan Anxiety disorders Midazolam (in-patient) Versed Procedural sedation Triazolam Halcion Sleep onset in insomnia


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