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Neuro Behavioral Med 3 > 38 - Substance Abuse > Flashcards

38 - Substance Abuse Flashcards

1
Q

What will we be focusing on today?

A
  • Medications for management of withdrawal and maintenance of abstinence
  • Psychiatric prescribing for active substance abusers
  • When to treat psychiatric symptoms after sobriety is achieved
  • Use of habit-forming medications for recovering substance abusers
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2
Q

What are the top drugs that are abused?

A

From most to least common

  • Marijuana
  • Pain relievers
  • Cocaine
  • Tranquilizers
  • Hallucinogens
  • Stimulants
  • Heroin
  • Inhalants
  • Sedatives
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3
Q

What is the current binge drinking levels?

A
  • 4 drinks in a male

- 3 drinks in a female

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4
Q

What are groups are the highest at binge drinking?

A

21-25

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5
Q

What is involved in comprehensive drug abuse treatment?

A
  • Child care services
  • Vocational services
  • Mental health services
  • Medical services
  • Educational services
  • HIV/AIDS services
  • Legal services
  • Financial services
  • Housing/transportation services
  • Family services

Don’t need to memorize this, but just realize that this is comprehensive and addicts rarely get it

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6
Q

Which substances need management of withdrawal?

A
  • Alcohol/Sedatives
  • Opiates
  • Nicotine
  • Cannabis
  • Cocaine/Stimulants
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7
Q

Describe the withdrawal of alcohol

A

Withdrawal from alcohol can be dangerous, causing seizures, hallucinations and even death *** (main concern)

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8
Q

How do you medically manage alcohol withdrawal?

A
  • Management of acute withdrawal typically involves a taper of benzodiazepines (Lorazepam, Diazepam or Chlordiazepoxide)
  • Benzodiazepines, like alcohol, activate the GABA neurotransmitter system.
  • With chronic alcohol abuse, GABA is downregulated. Among other things, Benzodiazepines allow a transition back to a safe level of GABA functioning.
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9
Q

So, how do you treat alcohol withdrawal?

A

BENZOS ***

know this ***

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10
Q

When someone is in withdrawal from illicitly-gained benzos, how do we treat them?

A

With benzos

Long acting, taper controlled benzos

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11
Q

How would you treat withdrawl-related hallucinations?

A

Withdrawal-related hallucinations can be treated with judicious use of antipsychotics (Haloperidol.)

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12
Q

Describe the treatment for the withdrawal of barbiturates

A
  • Benzos can also be used in withdrawal from Barbiturates (butabarbital, pentobarbital).
  • Phenytoin (an anti-epilepsy medicine) is another option.
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13
Q

Describe medications which can decrease the cravings or convulsions to drink alcohol

A

This aids in ALCOHOL ABSTINENCE –> Naltrexone ***

  • An opiate antagonist that interferes with the pleasure response to alcohol.
  • Seems to help decrease heavy drinking more than it helps total abstinence
  • Potential adverse effect on liver (not good for people who already have liver damage.)
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14
Q

What other drug can be used to decreased cravings or compulsions to drink?

A
  • Acamprosate (Campral) affects the balance of GABA and glutamate.
  • Helps reduce hyperarousal of early sobriety.
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15
Q

What is the other medication that is used to decrease cravings or compulsion to drink?

A

Topiramate

  • Topiramate (Topamax) is an anti-epilepsy medication that also helps put the brake on glutamate and increase GABA activity in the brain.
  • It can cloud the mind, so not great if you’re trying to go through withdrawal
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16
Q

Which drug for decreasing alcohol abuse makes “alcohol its own punishment”

A

Antabuse (disulfuram)

  • Disulfuram (Antabuse) inhibits acetaldehyde dehydrogenase, a necessary enzyme for metabolizing alcohol.
  • Leads to accumulation of acetaldehyde
  • Exposure to alcohol causes the person to become VERY ill
  • Compliance not great (understandably)
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17
Q

What are the opiates that can be abused?

A
  • Heroin
  • Opium
  • Methadone
  • Morphine
  • Oxycodone
  • Hydromorphone
  • Fentanyl
  • Hydrocodone
  • Meperidine
  • Propoxyphene
  • Codeine

All have similar effects and risk for abuse / dependence.

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18
Q

What are the effects of opiate withdrawal?

A

Withdrawal from opiates is utterly miserable, but rarely medically dangerous.

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19
Q

What are the two ways to handle opiate detox?

A
  • Symptomatic treatment

- Opiate replacement

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20
Q

Describe the symptomatic treatment method for opiate detox

A
  • Clonidine (centrally-acting anti-hypertensive) reduces the physiologic arousal of withdrawal
  • Dicyclomine (anti-cramping)
  • Loperamide (anti-diarrhea)
  • [less commonly] Benzodiazepines for anxiety/agitation/insomnia
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21
Q

Describe the opiate replacement method for opiate detox

A

Methadone

  • A long-acting opiate that can be used to taper off illicit opiates.
  • Distribution is highly controlled because of abuse potential.
  • It can also be used chronically for “harm reduction” as an alternative to illicits (obviously controversial.)
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22
Q

Describe the “harm reduction” model of chronic methadone treatment

A
  • The provider realizes that the risk of relapse is much more risky than the patient just being on this for the rest of their life - “chronic”
  • It is not ideal, but it is better than relapsing
23
Q

Describe the opiate replacement method with buprenorphine for the treatment of opiate withdrawal

A

Buprenorphine

  • A mixed opiate agonist / antagonist that can prevent withdrawal symptoms. It has less analgesic and euphoric effects than full agonists, and is thus less likely to itself be abused.
  • Buprenorphine must be started after the person is experiencing withdrawal. It can otherwise precipitate withdrawal symptoms.
24
Q

What is Suboxone?

** KNOW THIS **

A
  • Buprenorphine is frequently prescribed as Suboxone, where it is combined with Naloxone (a full opiate antagonist).
  • The Naloxone isn’t orally absorbed, but is present if someone tries to use Suboxone intravenously. It will prevent any euphoria and promptly put the user in withdrawal [ouch].
25
Q

Describe naltrexone as a treatment for opiate withdrawal

A

Naltrexone (the same opiate antagonist that can be used for maintaining alcohol abstinence) can be used to help maintain opiate abstinence. Though it doesn’t greatly reduce craving, it will prevent an opiate from having any pleasurable effect.

26
Q

How can you treat nicotine withdrawal?

A

Nicotine replacement as a means of ending tobacco use.

27
Q

What are the types of nicotine replacement?

A
  • Transdermal patch, gum, lozenges, inhalers

- Varenicline (Chantix) is a nicotinic receptor partial agonist prescribed as a way to transition away from tobacco.

28
Q

What are the concerns with varenicline?

A

There have been recent concerns raised about possible adverse psychiatric effects.

MONITOR THIS CLOSELY ***

29
Q

Describe bupropion as a treatment for nicotine withdrawal

A
  • This is just an anti-depressant that has been repackaged and marketed as a smoking-cessation drug
  • Bupropion (Wellbutrin, Zyban) is a norepinephrine/dopamine reuptake inhibitor.
  • It’s benefit may be related to dopamine effects on the reward pathway in the brain.
30
Q

Describe the withdrawal of cannabis/psychadelics

A

“Bummer dude”

  • Because there is NO medication that make this easier
  • Withdrawal is NOT medically dangerous
  • No medications have been found to specifically aid in acute withdrawal or in maintaining abstinence.
  • Symptomatic treatment of psychiatric symptoms can be helpful (more later)
31
Q

Describe the withdrawal seen in cocaine and stimulants

A
  • Withdrawal is related to depleted dopamine, norepinephrine and epinephrine supplies.
  • NO medications have been found to specifically aid in acute withdrawal***
32
Q

What drug might have some significant results in cocaine/stimulant withdrawal?

A

Studies of Topiramate (Topamax,) an anti-epilepsy medication, have had mixed results in helping to maintain abstinence

Not clinically used very much though, not a lot of data to support it

33
Q

Describe how you prescribe medications for the active substance abuser

A
  • Most antipsychotic, antidepressant and mood stabilizing medications are relatively safe even for someone who is abusing alcohol or drugs
34
Q

What are the EXCEPTIONS to this… What are the risky meds to give an active abuser?

A
  • Lithium: Diuresis from alcohol leads to dehydration, which in turn leads to higher blood levels of lithium and increased risk of toxicity.
  • Bupropion (Wellbutrin, Zyban) lowers the seizure threshold. Combined with even minor withdrawal, there is increased risk of seizure.
35
Q

What will you see in bupropion in active abusers?

A

More seizures

Not common, but it is a risk

36
Q

What particular types of drugs can be risky in active abusers?

A

SEDATING DRUGS

  • Sedating effects of any medication will be augmented by alcohol
  • Not necessarily lethal, but hard to live a life or engage in treatment.
37
Q

What specific drugs are sedating and particularly risky?

A

Benzodiazepines and Barbiturates will specifically combine with alcohol (all affecting GABA) to cause dangerous inhibition of brain activity. This can lead to respiratory suppression and death.

38
Q

What is important to know about alcohol and antidepressants?

A

Effectiveness of antidepressant medications will be very limited by alcohol use.

39
Q

What are the combinations of drugs that are risky for respiratory suppression

A

The combination of opiates with other sedating medication increases the risk of respiratory suppression.

  • Heath Ledger (oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine)
  • Michael Jackson (propofol, diazepam, midazolam)
40
Q

What type of health risks are associated with ADHD stimulant drugs?

A

Cardiac risks when combined with prescribed stimulants for ADHD (Methylphenidate, Amphetamine salts, Dextroamphetamine)

41
Q

What type of health risks are associated with antipsychotics?

A

Also risks with antipsychotics that affect cardiac rhythm (including Haloperidol, Risperidone, Quetiapine)

42
Q

Why do patients often smoke numerous packs of cigarettes a day?

A

Nicotine generally increases the metabolism of antipsychotics, which may result in reduced effectiveness for a given dose.

They do this because it reduces the mental cloudiness and side effects

43
Q

Describe how you decide whether or not to continue or discontinue treatment for abuse or withdrawal

A
  • If, even with treatment resources available and adequate education, a patient continues to abuse substances in a way that creates hazardous interactions with medications, discontinuation of the medication should be seriously considered.
44
Q

What if the medication is also treating a psychiatric disorder?

A

If stopping a medication would likely worsen psychiatric symptoms that are promoting substance abuse for “self-medicating,” continuation of the medication should be seriously considered.

45
Q

Describe the balance you need to consider

A
  • Giving psychiatric meds to someone in an active addiction can be like putting down fresh tablecloths on the Titanic – nice, but doesn’t really address the problem at hand.
  • Patients need to be told that AODA treatment will be necessary for true resolution of psychiatric symptoms

Can’t just take meds to reslove problems, NEED to consider AODA treatment

46
Q

What can be particularly beneficial for patients with drug addiction and psychiatric needs?

A
  • If there’s both high risk interactions and psychiatric need…well, that’s a pickle.
  • Never underestimate the power of a good therapeutic bond and close follow-up.
  • Patients need to know they won’t be abandoned by mental health providers if sobriety proves elusive (which it often is)
47
Q

What is INTEGRATED treatment?

A
  • It is well established that there is a high co-morbidity of substance use with many psychiatric conditions (and vice-versa.)
  • Treatment of one can be impaired if the other is ignored.
48
Q

What can drug abuse do to psychiatric symptoms?

A

Alcohol and illicit drugs (whether intoxication or withdrawal) can:

  • Cause psychiatric symptoms
  • Worsen psychiatric symptoms
  • Hide psychiatric symptoms

Psychiatric conditions can mimic symptoms of intoxication and withdrawal (mania)

49
Q

What is helpful in patients undergoing integrated treatment?

A

Reassurance that patients will have support and treatment available for agitation, depression, anxiety or insomnia can be key in their finding motivation to change.

50
Q

What type of education is important for patients for with substance abuse and psychiatric issues?

A

Education that abstinence will likely overall improve the above psychiatric symptoms is also important.

51
Q

At what point in abstinence is a symptom considered ‘psychiatric,’ as opposed to ‘substance-induced’?

A
  • Basically, when symptoms go beyond the severity and/or duration typical for abstinence from a given substance
  • Treatment will vary on a case-by-case basis.
52
Q

What is a problem we see in treating patients for substance abuse?

A

Ongoing use of habit-forming medications in recovery.

  • Benzodiazepines (anxiety, insomnia)
  • Stimulants (ADHD, depression adjunct)
  • (To abuse the simile): Are we just switching seats on the Titanic?
  • Just as with treatment of a non-addict, the benefits of a medication is measured in symptom reduction and increased functioning.

They might get addicted to the benzos you are prescribing and you use them improperly

53
Q

Give a summary of this lecture

A
  • Addiction is complex
  • Comorbidity with psychiatric illness is common
  • Effective treatment must address multiple needs
  • Many medications are available that aid in initial recovery and maintaining abstinence

Neuro Behavioral Med 3 (16 decks)

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