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PHRM 845 > 5.12 pharmacotherapy of substance use disorders > Flashcards

5.12 pharmacotherapy of substance use disorders Flashcards

1
Q

How does the DSM5 define substance use disorder?

A

Problematic pattern of substance use leading to clinically significant impairment or distress, with having two of the following occurring in a 12 month period:
- Taken in larger amounts; over a longer period than intended
- Persistent desire or unsuccessful efforts to control use
- Great deal of time spent in activities necessary to get substance or recover
- Craving, urge to use
- Recurrent use results in failure to fulfill major obligations
- Continued use despite social or interpersonal problems
- Continued use even though it’s hazardous
- Continued use despite realizing it’s harmful
- Tolerance
- Withdrawal

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2
Q

What is the presentation of having a BAC of 50 mg/dl (0.05 mg%)?

A

Motor function impairment observable

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3
Q

What is the presentation of having a BAC of 80 mg/dl (0.08 mg%)?

A
  • Moderate impairment
  • Legal definition of intoxication in most states
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4
Q

What is the presentation of having a BAC of 450 mg/dl?

A

Respiratory depression

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5
Q

What is the presentation of having a BAC of 500 mg/dl?

A
  • LD50 for ethanol
  • Lethal
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6
Q

What is the time of onset after withdrawal for alcohol withdrawal stage 1?

A

6-8h

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7
Q

What clinical features are present w alcohol withdrawal stage 1?

A
  • Moderate autonomic hyperactivity (anxiety, tachycardia, nausea, insomnia)
  • Craving for alcohol
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8
Q

What is the time of onset after withdrawal for alcohol withdrawal stage 2?

A

24h

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9
Q

What clinical features are present w alcohol withdrawal stage 2?

A
  • Autonomic hyperactivity w auditory or visual hallucinations lasting 1-3 days
  • Most remain lucid and oriented
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10
Q

What is the time of onset after withdrawal for alcohol withdrawal stage 3?

A

1-2 days

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11
Q

What clinical features are present with alcohol withdrawal stage 3?

A

4% of untreated pts develop grand mal seizures 7-48h after drop in BAC

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12
Q

What is the time of onset after withdrawal for alcohol withdrawal stage 4?

A

3-5 days

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13
Q

What clinical features are present w alcohol withdrawal stage 4?

A

Delirium tremens (DTs) in 5% of pts (confusion, illusions, hallucinations, agitation, tachycardia, hyperthermia)

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14
Q

What are risk factors for delirium tremens?

A
  • Prior hx of DTs (#1 predictor of future DTs)
  • # of detoxifications
  • Consuming equivalent to 1pint of whiskey/day for 10-14 days prior to admission
  • Early sxs of withdrawal
  • Hepatic dysfxn
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15
Q

Pts w DTs can experience something called kindling. What is kindling?

A

Repeated withdrawal episodes increases the severity of subsequent withdrawal syndromes

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16
Q

What is the prophylaxis/fixed dosing tx of alcohol withdrawal?

A
  • No liver dysfxn: diazepam, chlordiazepoxide, lorazepam, oxazepam
  • W liver dysfxn: lorazepam, oxazepam
  • May also use lorazepam PRN to supplement
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17
Q

What is the advantage of using a prophylaxis/fixed dosing tx for alcohol withdrawal?

A

Prevent withdrawal

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18
Q

What is the disadvantage of using a prophylaxis/fixed dosing tx for alcohol withdrawal?

A

Unnecessary BZD dosing

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19
Q

What is the individualized dosing tx of alcohol withdrawal?

A
  • CIWA <8: Nonpharm tx
  • CIWA 8-15: Medicate
  • CIWA >15: Risk of complications if untx
  • No liver dysfxn: diazepam, chlordiazepoxide, lorazepam, oxazepam
  • W liver dysfxn: lorazepam, oxazepam
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20
Q

Should phenytoin be used for alcohol withdrawal?

A
  • Takeaway: phenytoin doesn’t work
  • Not effective to tx withdrawal seizures
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21
Q

What is always recommended if there is any suspicion of alcohol abuse?

A

Thiamine 100mg daily, usually duration of hospital stay –> reduce risk of Wernicke’s

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22
Q

What is Wernicke’s a result of?

A

Thiamine deficiency

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23
Q

When should thiamine be given?

A

Give before dextrose-containing fluids

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24
Q

Why is thiamine required to prevent Wernicke’s?

A
  • Thiamine is a cofactor in glucose metabolism
  • Wernicke’s can be precipitated by high glucose loads
25
Q

What other drugs are used for alcohol use disorder?

A
  • Disulfiram (Antabuse)
  • Acamprosate (Campral)
  • Naltrexone
26
Q

What is disulfiram (antabuse) used for?

A

Aversive therapy for alcohol withdrawal

27
Q

What does disulfiram (antabuse) cause?

A

Unpleasant effects if alcohol is used

28
Q

What is a risk w disulfiram (antabuse)?

A

Potential for CV collapse, death w excessive alcohol

29
Q

What happen after disulfiram (antabuse) d/c?

A
  • Disulfiram rxn for up to 14 days after d/c
  • Bc aldehyde dehydrogenase inhibition irreversible
30
Q

What is acamprosate (campral) used for?

A

Maintenance of alcohol abstinence

31
Q

How is acamprosate (campral) eliminated and why is this important?

A
  • Renal elimination, monitor renal fxn
  • IMPORTANT: avoid in severe renal impairment
32
Q

What is a warning with acamprosate (campral) and SEs?

A
  • Suicidality warning
  • Diarrhea, nausea, depression, anxiety
33
Q

What is naltrexone cause?

A

Decreases binge drinking, helps to increase time between drinking days

34
Q

What is common w naltrexone use and must be monitored?

A
  • Elevated LFTs common
  • Must monitor at baseline and routinely
35
Q

What must be evaluated w naltrexone use and why?

A
  • Evaluate pain management needs
  • Pt should have card or be able to tell providers they are on naltrexone bc naltrexone is an opioid antagonist
36
Q

What is a warning for naltrexone?

A

Injection site rxns

37
Q

What is the tx for muscle aches/tension of opioid withdrawal?

A

Acetaminophen or NSAID

38
Q

What is the tx for agitation/anxiety/insomnia of opioid withdrawal?

A

Hydroxyzine/benzos

39
Q

What is the tx for abdominal cramping/nausea/vomiting of opioid withdrawal?

A

Ondansetron

40
Q

What is the tx for diarrhea of opioid withdrawal?

A

Loperamide

41
Q

What is the tx for sweating/yawning/increased tearing/runny nose of opioid withdrawal?

A

Clonidine or lofexidine

42
Q

What are alpha2 agonists used for in opioid withdrawal sxs?

A

Treating noradrenergic sxs can serve as entry to longer-term tx w MOUD and psychosocial tx

43
Q

What are the alpha2 agonist drugs used in opioid withdrawal tx?

A
  • Clonidine
  • Lofexidine
44
Q

What is the most common SE w clonidine?

A

Hypotension

45
Q

Which drugs are maintenance tx for opioid use disorder?

A
  • Methadone
  • Buprenorphine
46
Q

What is a requirement for dispensing of methadone?

A

Methadone must be given in a licensed tx program

47
Q

How is buprenorphine usually given and why?

A
  • In combo w naloxone in a SL tablet or film strip dosage form
  • Poor bioavailability when swallowed, must be SL
48
Q

What CYP interactions does methadone have and what are cautions due to it?

A
  • P450 2B6, 3A4, 2C19, 2D6 substrate
  • Use w caution in pts also taking moderate to strong inhibitors or inducers
49
Q

What is a serious concern w methadone and must be monitored?

A
  • QTc prolongation is a serious concern
  • ECG monitoring is recommended
50
Q

When should buprenorphine therapy be initiated?

A
  • To avoid precipitating withdrawal, initiate therapy when there are clear signs of withdrawal
  • Admin in divided doses on day 1
51
Q

What must be monitored w buprenorphine use?

A
  • Monitor LFTs
  • Use w serotonergic drugs may cause serotonin syndrome
52
Q

What is a lesser concern w buprenorphine use and why?

A
  • Risk of respiratory depression in OD is much less than w opioids, including methadone
  • Due to partial agonist effect
53
Q

What is buprenorphine extended-release injection used for?

A

For moderate-severe opioid use disorder

54
Q

How is buprenorphine extended-release injection administered?

A

Pts initiated on SL buprenorphine and dose adjustments for at least 7 days prior to 1st injection

55
Q

When is methadone more preferable?

A
  • More effective
  • FDA approved for use in pregnancy
56
Q

When is buprenorphine more preferable?

A

Effective in tx over short term

57
Q

When is naltrexone long-acting injection a good choice?

A

For pt w alcohol AND opioid use disorders

58
Q

What is common w substance withdrawal?

A

Depression
- May last for months after d/c of cocaine
- Tx like clinical depression

PHRM 845 (48 decks)

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