Addiction Flashcards
1
Q
Define Recreational Drug Use
A
Use either alone or with other drugs to induce or enhance a drug experience for performance enhancement or for cosmetic purposes
2
Q
Define Illicit Drug Use
A
Use of illegal drugs, misuse of pharmaceutical drugs and/or use of other psychoactive substances in a harmful way
3
Q
What is Addiction?
A
Chronic, relapsing disorder characterised by compulsive drug seeking and use despite adverse consequences
4
Q
What are the Characteristics of Addition?
A
- Tolerance to effect of the drug – need greater amounts to maintain the same effect
- Loss of control of the frequency and amount of use
- Excessive time spent using or obtaining the drug at the expense of other activities
- Continued drug use despite associated problems
- Withdrawal when drug is ceased
5
Q
Define Substance Use Disorder
A
Current DSM-V term for a spectrum of problematic drug use patterns, encompassing drug abuse, through to drug addiction
6
Q
Drug addiction is considered what?
What does it involve?
A
- Drug addiction is considered a brain disorder
- It involves functional changes to brain circuits involved in reward, stress and self-control and those changes may last a long time after a person has stopped taking drugs
7
Q
What plays a key role in mediating reward in drug addiction?
A
- Dopamine release in the mesolimbic pathway plays key role in mediating reward
- These regions involved in learning of environmental cues and feeling of reward
8
Q
What are the Risk Factors that Contribute to Developing Addiction?
A
- Aggressive behaviour in childhood
- Lack of parental supervision
- Poor social skills
- Drug experimentation
- Availability of drugs at school
- Community poverty
9
Q
What are the Protective Factors that Contribute to Developing Addiction?
A
- Good self-control
- Parental monitoring and support
- Positive relationships
- Good schooling grades
- School anti-drug policies
- Neighbourhood resources
10
Q
What factors contribute to harm minimisation?
A
- Demand reduction
- Prevent uptake and delay first use
- Reduce harmful use
- Supply reduction
- Control illicit drug and precursor availability
- Reduce illicit drug availability and accessibility
- Harm reduction
- Reduce risk behaviours
- Safer settings
11
Q
What is Motivational Interviewing?
A
- Instead of directing/advising patients on what they should do, guide patients to make a decision themselves
- Reflect with patient on their current situation, aim to develop discrepancy between current state and desired state
12
Q
What are Opium, Opiates and Opioids?
Where do they come from and what do they contain?
A
- Opium is a naturally occurring substance derived from the poppy plant
- The opium latex contains opiates, morphine and codeine
- Opioids are natural or synthetic drugs that bind to and agonise opioid receptors
13
Q
Is an opioid withdrawal life threatening?
A
- Withdrawal extremely uncomfortable but not life threatening
14
Q
What are the 2 Approaches for Managing an Opioid Use Disorder?
A
- Withdrawal/detoxification ‘detox’
- Symptomatic treatment to help manage symptoms of withdrawal
- Bridging substitution therapy (+ maintenance of abstinence)
- Longer acting opioid to help during the time coming off opioid
- Harm minimisation approach (substitute problematic opioid use with prescribed opioid)
- Opioid substitution therapy
- Take home naloxone
- Safe injecting practices if they still want to inject
- Pharmacological interventions should be combined with psychosocial interventions such as counselling, CBT and social support
15
Q
Buprenorphine
- MOA?
- Duration of action?
- Characteristics for Opioid Withdrawal?
A
- High affinity, partial opioid receptor agonist (binds to same receptors as morphine, heroin, but when it binds, doesn’t activate to same degree)
- Long duration of action
- Buprenorphine for Opioid Withdrawal
- Defined tapering course can be used to assist detoxification
- Long half-life minimises symptoms due to acute withdrawal
- Fixed daily dose OR flexible dose range
- Don’t administer until objective signs of withdrawal, start with small test dose
16
Q
Naltrexone
- MOA?
- Duration of action?
- Use for opioid use disorder?
- Issues?
A
- Long acting, orally active opioid antagonist
- Rarely used for opioid use disorder due to limited efficacy
- Issues:
- Requires person to be committed and only a small proportion of patients are actually adherent
- Additional increased risk of overdose (if go back to using) as may accelerate loss of tolerance that occurs when people are abstinent from opioids
17
Q
Illicit Opioid Substituted for Prescribed Opioid aims to:
A
- Reduce risks associated with overdose and IV administration
- Reduce use of illicit opioids
- Reduce criminal behaviour to finance habit
- Reduce the severity of withdrawal symptoms
- Enable access to psychosocial support
- Manages craving to allow patient to get the rest of their life back on track
18
Q
What are Opioid Substitution Therapy Programs?
A
- Individual attends clinic or pharmacy to collect prescribed dose of methadone or buprenorphine most days
- Dose taken on the spot, observed by health professional
- When stabilised patient can apply for ‘take away’ doses
19
Q
Are Opioid Substitution Therapy Programs effective?
Treatment duration?
A
- More effective in decreasing illicit opioid use than no treatment, placebo treatment, detoxification
- Better outcomes achieved when higher doses are used for longer periods
- Usual treatment duration: 2-3 years but can be life long
20
Q
Methadone
- MOA?
- Position in OST?
- Duration of action?
- Risk of overdose?
- Strength Available?
- Dosing?
A
- Opioid agonist, some affinity for NMDA receptors
- Gold standard for OST
- Longer duration of action than heroin
- Greater risk of overdose and more sedation compared to buprenorphine (because methadone is full agonist)
- Available as 5mg/1mL syrup or oral liquid
- Individualised dosing – start low and taper up according to withdrawal symptoms and tolerability
21
Q
Monitoring with Methadone
A
- Liver function to be assessed before treatment
- Can cause prolongation of QT interval with high doses
- Consider interactions
22
Q
Methadone Regulations - T/A doses
A
- Regulations on how take-away doses are dispensed
- Child proof containers required
- Make dose up to specific volume with water
23
Q
What is the Purpose of Buprenorphine-Naloxone Sublingual?
A
- Buprenorphine will enter the body and partially bind to opioid receptors with a high affinity
- Naloxone attenuates the effects of buprenorphine if injected and precipitate withdrawal in individuals dependent on full opioid agonists
24
Q
Buprenorphine-Naloxone Sublingual
- Half-life? What does this sllow?
- Initiate at?
- When is stabilisation required?
A
- Long half-life can allow alternative day dosing
- Initiate at 2-8mg sublingual, titrate to relieve withdrawal
- Stabilisation usually required 2-3 weeks
25
Buprenorphine alone also available in SL tablets - What is the purpose of these?
* Pregnancy or allergy
26
What are the Drivers of Long Acting Depot Buprenorphine?
* Current focus on supervised daily dosing
* Can be onerous and restrictive for patients
* Can be counterproductive to ‘normalised’ life
* May be const benefits for patients, dosing and transport
* Reduced opportunity for diversion, misuse, poisoning
27
How is Opioid Withdrawal Managed?
* Tapering doses of buprenorphine now mainstay for bridging during opioid withdrawal (replaced clonidine and tapering methadone)
* Under supervision: patient can consider diazepam for anxiety/agitation or temazepam for insomnia
* Avoid in outpatient setting
28
Symptomatic Medication to treat opioid withdrawal symptoms:
* Diarrhoea
* Nausea or vomiting
* Muscle cramps or pain
* Insomnia
* Agitation and anxiety
* **Diarrhoea** – loperamide
* **Nausea or vomiting** – metoclopramide
* **Muscle cramps or pain** – ibuprofen, paracetamol, hyoscine butylbromide
* **Insomnia** – psychological support
* **Agitation and anxiety** – psychological support
29
What are the 2 Products in Long Acting Depot Buprenorphine?
* Buvidal
* Sublocade
30
Long Acting Depot Buprenorphine: 2 Products - Buvidal
* How often is it administered?
* Vs. Suboxone?
* Weekly or monthly administration by health professional
* Less cumulative illicit opioid use vs suboxone
31
Long Acting Depot Buprenorphine: 2 Products - Sublocade
* How often is it administered?
* Vs. Placebo?
* Requires?
* Monthly administration by health professional
* Significantly higher percentage of patients abstinent vs. placebo
* Requires cold chain transport, refrigerate, stable at room temperature for max 7 days
32
Long Acting Depot Buprenorphine - Discuss the Efficacy and Safety
* Rapid and sustained withdrawal suppression
* Rapid and sustained opioid blockade
* High treatment retention
* Serious harm or death could result if administered intravenously
33
* OST During Pregnancy
* What's 1st line?
* How is it dosed?
* What needs to be considered?
* Risk to baby?
* 1st line: methadone
* Growing data show equivalent or superior outcomes with buprenorphine
* Current guidelines recommend buprenorphine alone (vs with naloxone)
* May need to split methadone dose (BD)
* Consider lost doses due to vomiting
* Baby likely to experience neonatal abstinence syndrome, but risks of illicit use without treatment greater
34
What are the Symptoms of Neonatal Abstinence Syndrome?
* Sneezing
* Sweating
* Hyperthermia
* Tremor
* Diarrhoea
* Vomiting
* Hypertension
* Tachycardia
* Seizures
* Sleep deprivation
* High-pitched cry
35
**Naloxone**
* MOA?
* Indication?
* Safety profile?
* Competitive antagonist at opioid receptors
* Used to reverse opioid overdose – very effective
* Safety profile
* Very few adverse effects
* No abuse potential
* No effect if given to healthy individual without opioid use
* Unlikely to cause harm if unresponsive for another reason
36
What are the Indicators of Risk for Opioid Overdose?
* Recent medical care for opioid overdose/intoxication
* Suspected/confirmed history of heroin or non-medical opioid use
* Prescription for high dose or long acting opioid
* Resuming opioid use after loss of tolerance due to detox, rehab or prison
* Opioids prescribed for patients with comorbid respiratory, renal, hepatic, cardiac or mental health conditions
* Concurrent use of other CNS depressants
37
What is Nyoxid (Naloxone)?
Single dose nasal spray device, 2 devices per pack
38
What is the Importance of Naloxone Monitoring Post Administration?
* Stay with the patient and monitor response
* Risk of relapse if naloxone wears off before opioid
39
Guidelines for Drinking Alcohol: Reducing risk of alcohol related harm over a lifetime?
Drink no more than 2 standard drinks on any given day
40
Guidelines for Drinking Alcohol: Reducing risk of injury while drinking?
Drink no more than 4 standard drinks on any one occasion
41
Guidelines for Drinking Alcohol: Young people \< 18 years old?
Avoid alcohol if under 18 is the safest option
42
Guidelines for Drinking Alcohol: Pregnancy and Breastfeeding?
Avoid alcohol is the safest option
43
Alcohol Use Disorder - How is it Managed?
* Withdrawal/Detoxification
* Alcohol withdrawal seizures
* Delirium tremens
* Wernicke Korsakoff Syndrome
* Medications to prevent complications
* Maintaining abstinence or reduced intake
* Pharmacological interventions should be combined with psychosocial interventions (mainstay)
44
Alcohol Withdrawal - What are the 2 Ways it's managed?
* Home ‘detox’ possible if:
* Mild-moderate withdrawal predicted
* No medical/psychiatric complications
* Daily GP/Drug and Alcohol Services input
* Supportive (non-drinking) carer
* Inpatient ‘detox’ required if:
* Severe withdrawal predicted from drinking history, comorbidities, concurrent CNS meds, history of seizures
* Unsuccessful home detox in past
45
Alcohol Withdrawal
* What is the onset?
* In severely dependent drinkers?
* Onset is usually 6-24 hours after last drink
* In severely dependent drinkers, reducing alcohol intake may precipitate withdrawal even if still drinking
46
Managing Alcohol Use Disorder – Withdrawal Seizures
* When do they occur?
* What are the types of seizures?
* Occur early (7-24 hour post last drink)
* Generalised seizures, usually single episode
47
Managing Alcohol Use Disorder – Delirium Tremens
* What can it cause?
* Is it an emergency?
* When do the symptoms occur?
* What are the clinical features?
* Most severe form of alcohol withdrawal – MEDICAL EMERGENCY (can cause CV collapse/heart failure)
* Symptoms usually occur 2-4 days post last drink
* Clinical Features
* Gross body tremors
* Autonomic instability (BP and HR)
* Confusion
* Fluid and electrolyte imbalance
* Sensitivity to light sound, touch
* Hallucinations, paranoid ideation
48
Managing Alcohol Use Disorder – Wernicke-Korsakoff Syndrome
* Cause?
* If not treated?
* Signs?
* Brain injury resulting from Thiamine (B1) deficiency
* If not treated early can lead to permanent brain damage from memory loss
* Wernicke’s encephalopathy usually first stage of syndrome, signs include:
* Reduced eye movements
* Ataxia
* Confusion
49
Benzodiazepines in Alcohol Withdrawal
* Are they used?
* First line? reduce, avoid?
* IV?
* Oxazepam?
* Mainstay of treatment: sedative and anticonvulsant properties
* Help with anxiety and insomnia
* First line = diazepam
* Reduce dose if concurrent CNS depressants e.g. pregabalin
* Avoid if significant liver disease
* Lorazepam alternative in patients with liver disease
* If IV needed = clonazepam
* Oxazepam NOT recommended as less effective for seizures
50
Other Medications Used During Alcohol Withdrawal?
* Standard to commence a multivitamin
* May also require:
* Other anticonvulsants short term (e.g. CBZ, phenytoin)
* IV fluids
* Anti-emetics
* Antipsychotics
* Simple analgesics
51
What are the 2 aims in Managing Alcohol Dependence?
* Controlled drinking is an option for some individuals = learn to drink moderately
* OR -
* Aim for complete abstinence
* May be the only option for some people
* May attend therapeutic community, rehab
* Pharmacotherapies can support abstinence
52
There are 2 types of meds used in managing alcohol dependence.
What are they and what are their role?
* Older Medications – make alcohol consumption uncomfortable
* Disulfram
* New medications – reduce alcohol craving (don’t influence the effects of alcohol)
* Acamprosate: Support ongoing abstinence from alcohol
* Naltrexone: Decrease alcohol intake with abstinence not achieved
53
Meds used in managing alcohol dependence: Disulfram
* MOA?
* Leads to?
* Symptoms developed depend on?
* When to commence?
* Avoid alcohol for?
* Interferes with metabolism of alcohol, increases acetaldehyde
* Leads to vomiting, headache, palpitations, potential hypotension
* Symptoms developed depend on amount of alcohol consumed
* Wait 24 hrs post last drink before commencing
* Avoid alcohol for 7 days after ceasing treatment
54
Meds used in managing alcohol dependence: Acamprosate
* What does it reduce and prolong?
* When to commence?
* Adverse effects?
* Reduces craving for alcohol and protracted withdrawal symptoms, prolongs abstinences, reduces drinking days
* Commence after acute withdrawal (e.g. 1 week post last drink)
* Adverse effects: rash diarrhoea, changes in libido
55
Meds used in managing alcohol dependence: Naltrexone
* What does it reduce?
* How does it work?
* Monitor?
* Adverse effects?
* Some reduction in craving, intoxication unaffected
* Reduces relapse to heavy drinking
* Interfere with opioid analgesics, avoid use together
* Monitor:
* Check LFTs prior and monitor throughout tmt, CI in liver failure
* Adverse effects: Nausea, dizziness – subsides over 1-2 weeks
56
Other Drugs used for Managing Alcohol Dependence
* Baclofen
* Ondansetron
* Topiramate
* Prazosin
57
Managing Alcohol Use Disorder During Pregnancy
* Alcohol has harmful effects on the foetus
* Foetal Alcohol Spectrum Disorder
* Withdrawal increases risk of spontaneous abortion and pre-term delivery
58
Problematic Benzodiazepine Use
* Is dependence common?
* What to encourage?
* Dependence rare with therapeutic doses over short periods (\<2 weeks)
* Risk increases with increased duration and/or dose
* Encourage patients on long term benzos to taper down and cease
59
Is Benzodiazepine Overdose Life-Threatening?
* Not usually life threatening
* Risk increase when combined with opioids and/or alcohol
60
What is used to treat Benzo overdose?
* Flumazenil
* Competitive GABA antagonist, reversal agent
61
What influences withdrawal timeline of benzodiazepines?
Half-life of benzodiazepines vary substantially; some have active metabolites which influences withdrawal timeline
62
How is Benzodiazepine Withdrawal Managed?
* Short term use: cease abruptly
* Use for several months: reduce by 15% per week
* High dose use:
* Convert to diazepam, reduce by 5-10% per week
* If expect severe withdrawal, treat as inpatient, tapering diazepam, can reduce more quickly
63
* THC is metabolised by?
* Can dependence develop?
* What can be prescribed during withdrawal?
* Cannabis use may increase likelihood of what diagnosis?
* THC metabolised by CYP2C9 and CYP3A4, potential for increased effects with inhibitors
* Dependence and Withdrawal
* Dependence can develop with regular frequent use
* Symptomatic meds may be prescribed during withdrawal
* Antiemetics, simple analgesia, benzodiazepines, antipsychotics
* Cannabis use may increase likelihood of subsequent schizophrenia diagnosis
64
What are the 3 Stimulants?
* Amphetamines
* Cocaine
* MDMA
65
What are the Forms of Metamphetamine and their relative potencies?
* Crystal – medium to high potency (usually most potent)
* Base – medium to high potency
* Powder – low to medium potency
66
Methamphetamine Induced Psychosis is what?
What are the Types of Symptoms?
* Serious potential side-effect of heavy methamphetamine use
* Types of Symptoms
* Paranoia and hallucinations
* Can be mild to severe
67
Amphetamine withdrawal - Are meds effective?
No meds shown to be effective, benzos may reduce irritability
68
Cocaine Withdrawal
What is it effective?
What can cocaine dependence respond to?
* Cognitive behavioural therapy effective
* Cocaine dependence may respond to disulfram
69
MDMA Withdrawal
* Is overdose fatal?
* What are the most significant toxic effects?
* Treatment is?
* Overdose may be fatal
* Hyperthermia and hyponatraemia are the most significant toxic effects
* Treatment includes reducing temperature, correction of fluid and electrolytes
70
MDMA
* Does it follow linear PK, where is it metabolised?
* What are the drug interactions?
* Non-linear PK, 80% metabolised in liver
* Drug interactions with CYP2D6 or CYP3A4 inhibitors (+ serotonergic agents)
71
Serotonin Syndrome and Illicit Drugs
* What changes?
* Caused by?
* What drugs?
* Mental, autonomic and neuromuscular changes that range in severity
* Almost always caused by drug interaction between 2 or more serotonergic drugs
* Serotonin syndrome reported with meth/amphetamine, MDMA, cocaine and LSD use
72
Pharmacological Treatments Available that have shown to assist smoking cessation – should be recommended to all patients interested in quitting
What are they?
* Nicotine Replacement Therapy (NRT)
* Varenicline (Champix)
* Slow release bupropion (Zyban SR)
* Nortriptyline
73
Nicotine Replacement Therapy
* What is it?
* Can you used more than 1?
* How long should it be continued for?
* Pharmacokinetics?
* Smoking increases ability to?
* Alternative nicotine source to reduce craving and withdrawal
* More than one form can be used concurrently with increased success rates and no increase in safety risk
* Continue NRT for 6-8 weeks, up to 12 weeks
* Pharmacokinetics
* NRT generally produces lower plasma nicotine levels vs. cigarettes so NRT titrated to manage craving/withdrawal
* Can combine 2 to get plasma level similar to what they usually have
* Smoking increases ability to metabolise caffeine
* If reduce smoking, should reduce caffeine to prevent symptoms of caffeine ‘overdose’
74
How does Varenicline work?
* Partial agonist at alpha-4-beta-2 nicotinic receptor
* Blocks nicotine prevents reward from smoking and partially activates receptor to minimise nicotine withdrawal
75
What are the Adverse Effects of Varenicline?
When can people smoking until?
* Nausea, dyspepsia
* Stop smoking week 2
76
Bupropion for Smoking Cessation
* When is it started?
* Duration?
* Caution?
* Can cause?
* Start 7 days before stopping smoker
* 9-week course
* Caution with hx of seizures, bipolar disorder and hypertension
* Caution with drugs that lower seizure threshold and CYP2D6 substrates
* Can cause false positive for amphetamines on urine drug screen
77
Nortriptyline for Smoking Cessation
* MOA?
* Commence treatment?
* A/Es?
* MOA independent to A/D effects
* Commence treatment 10-28 days before cessation
* Continue for 12 weeks post cessation
* Range of anticholinergic A/Es
* Can be toxic in overdose, potential for drug interactions
78
* What are Vaping Devices?
* Is nicotine approved by TGA?
* Is nicotine legal?
* Battery-powered devices that delivers nicotine vapour without tobacco smoke
* Nicotine liquid not approved by TGA
* Legal to import, possess and use nicotine for vaping with Rx from doctor
* Illegal to sell within Australia, can sell vaping device and flavourings
