Addiction Flashcards
Define Recreational Drug Use
Use either alone or with other drugs to induce or enhance a drug experience for performance enhancement or for cosmetic purposes
Define Illicit Drug Use
Use of illegal drugs, misuse of pharmaceutical drugs and/or use of other psychoactive substances in a harmful way
What is Addiction?
Chronic, relapsing disorder characterised by compulsive drug seeking and use despite adverse consequences
What are the Characteristics of Addition?
- 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
Define Substance Use Disorder
Current DSM-V term for a spectrum of problematic drug use patterns, encompassing drug abuse, through to drug addiction
Drug addiction is considered what?
What does it involve?
- 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
What plays a key role in mediating reward in drug addiction?
- Dopamine release in the mesolimbic pathway plays key role in mediating reward
- These regions involved in learning of environmental cues and feeling of reward
What are the Risk Factors that Contribute to Developing Addiction?
- Aggressive behaviour in childhood
- Lack of parental supervision
- Poor social skills
- Drug experimentation
- Availability of drugs at school
- Community poverty
What are the Protective Factors that Contribute to Developing Addiction?
- Good self-control
- Parental monitoring and support
- Positive relationships
- Good schooling grades
- School anti-drug policies
- Neighbourhood resources
What factors contribute to harm minimisation?
- 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
What is Motivational Interviewing?
- 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
What are Opium, Opiates and Opioids?
Where do they come from and what do they contain?
- 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
Is an opioid withdrawal life threatening?
- Withdrawal extremely uncomfortable but not life threatening
What are the 2 Approaches for Managing an Opioid Use Disorder?
- 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
Buprenorphine
- MOA?
- Duration of action?
- Characteristics for Opioid Withdrawal?
- 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
Naltrexone
- MOA?
- Duration of action?
- Use for opioid use disorder?
- Issues?
- 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
Illicit Opioid Substituted for Prescribed Opioid aims to:
- 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
What are Opioid Substitution Therapy Programs?
- 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
Are Opioid Substitution Therapy Programs effective?
Treatment duration?
- 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
Methadone
- MOA?
- Position in OST?
- Duration of action?
- Risk of overdose?
- Strength Available?
- Dosing?
- 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
Monitoring with Methadone
- Liver function to be assessed before treatment
- Can cause prolongation of QT interval with high doses
- Consider interactions
Methadone Regulations - T/A doses
- Regulations on how take-away doses are dispensed
- Child proof containers required
- Make dose up to specific volume with water
What is the Purpose of Buprenorphine-Naloxone Sublingual?
- 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
Buprenorphine-Naloxone Sublingual
- Half-life? What does this sllow?
- Initiate at?
- When is stabilisation required?
- Long half-life can allow alternative day dosing
- Initiate at 2-8mg sublingual, titrate to relieve withdrawal
- Stabilisation usually required 2-3 weeks
Buprenorphine alone also available in SL tablets - What is the purpose of these?
- Pregnancy or allergy
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
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
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
What are the 2 Products in Long Acting Depot Buprenorphine?
- Buvidal
- Sublocade
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
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
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
- 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
What are the Symptoms of Neonatal Abstinence Syndrome?
- Sneezing
- Sweating
- Hyperthermia
- Tremor
- Diarrhoea
- Vomiting
- Hypertension
- Tachycardia
- Seizures
- Sleep deprivation
- High-pitched cry
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
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
What is Nyoxid (Naloxone)?
Single dose nasal spray device, 2 devices per pack
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
Guidelines for Drinking Alcohol: Reducing risk of alcohol related harm over a lifetime?
Drink no more than 2 standard drinks on any given day
Guidelines for Drinking Alcohol: Reducing risk of injury while drinking?
Drink no more than 4 standard drinks on any one occasion
Guidelines for Drinking Alcohol: Young people < 18 years old?
Avoid alcohol if under 18 is the safest option
Guidelines for Drinking Alcohol: Pregnancy and Breastfeeding?
Avoid alcohol is the safest option
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)
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
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
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
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
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
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
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
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
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
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
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
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
Other Drugs used for Managing Alcohol Dependence
- Baclofen
- Ondansetron
- Topiramate
- Prazosin
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
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
Is Benzodiazepine Overdose Life-Threatening?
- Not usually life threatening
- Risk increase when combined with opioids and/or alcohol
What is used to treat Benzo overdose?
- Flumazenil
- Competitive GABA antagonist, reversal agent
What influences withdrawal timeline of benzodiazepines?
Half-life of benzodiazepines vary substantially; some have active metabolites which influences withdrawal timeline
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
- 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
What are the 3 Stimulants?
- Amphetamines
- Cocaine
- MDMA
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
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
Amphetamine withdrawal - Are meds effective?
No meds shown to be effective, benzos may reduce irritability
Cocaine Withdrawal
What is it effective?
What can cocaine dependence respond to?
- Cognitive behavioural therapy effective
- Cocaine dependence may respond to disulfram
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
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)
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
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
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’
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
What are the Adverse Effects of Varenicline?
When can people smoking until?
- Nausea, dyspepsia
- Stop smoking week 2
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
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
- 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
