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Pharmacotherapeutics Theory 2 > Addiction > Flashcards

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

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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

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3
Q

What is Addiction?

A

Chronic, relapsing disorder characterised by compulsive drug seeking and use despite adverse consequences

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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
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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

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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
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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
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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
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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
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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
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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
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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
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13
Q

Is an opioid withdrawal life threatening?

A
  • Withdrawal extremely uncomfortable but not life threatening
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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
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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
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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
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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
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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
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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
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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
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21
Q

Monitoring with Methadone

A
  • Liver function to be assessed before treatment
  • Can cause prolongation of QT interval with high doses
  • Consider interactions
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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
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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
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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
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25
Q

Buprenorphine alone also available in SL tablets - What is the purpose of these?

A
  • Pregnancy or allergy
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26
Q

What are the Drivers of Long Acting Depot Buprenorphine?

A
  • 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
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27
Q

How is Opioid Withdrawal Managed?

A
  • 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
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28
Q

Symptomatic Medication to treat opioid withdrawal symptoms:

  • Diarrhoea
  • Nausea or vomiting
  • Muscle cramps or pain
  • Insomnia
  • Agitation and anxiety
A
  • Diarrhoea – loperamide
  • Nausea or vomiting – metoclopramide
  • Muscle cramps or pain – ibuprofen, paracetamol, hyoscine butylbromide
  • Insomnia – psychological support
  • Agitation and anxiety – psychological support
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29
Q

What are the 2 Products in Long Acting Depot Buprenorphine?

A
  • Buvidal
  • Sublocade
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30
Q

Long Acting Depot Buprenorphine: 2 Products - Buvidal

  • How often is it administered?
  • Vs. Suboxone?
A
  • Weekly or monthly administration by health professional
  • Less cumulative illicit opioid use vs suboxone
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31
Q

Long Acting Depot Buprenorphine: 2 Products - Sublocade

  • How often is it administered?
  • Vs. Placebo?
  • Requires?
A
  • 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
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32
Q

Long Acting Depot Buprenorphine - Discuss the Efficacy and Safety

A
  • Rapid and sustained withdrawal suppression
  • Rapid and sustained opioid blockade
  • High treatment retention
  • Serious harm or death could result if administered intravenously
33
Q
  • OST During Pregnancy
    • What’s 1st line?
    • How is it dosed?
    • What needs to be considered?
    • Risk to baby?
A
  • 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
Q

What are the Symptoms of Neonatal Abstinence Syndrome?

A
  • Sneezing
  • Sweating
  • Hyperthermia
  • Tremor
  • Diarrhoea
  • Vomiting
  • Hypertension
  • Tachycardia
  • Seizures
  • Sleep deprivation
  • High-pitched cry
35
Q

Naloxone

  • MOA?
  • Indication?
  • Safety profile?
A
  • 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
Q

What are the Indicators of Risk for Opioid Overdose?

A
  • 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
Q

What is Nyoxid (Naloxone)?

A

Single dose nasal spray device, 2 devices per pack

38
Q

What is the Importance of Naloxone Monitoring Post Administration?

A
  • Stay with the patient and monitor response
  • Risk of relapse if naloxone wears off before opioid
39
Q

Guidelines for Drinking Alcohol: Reducing risk of alcohol related harm over a lifetime?

A

Drink no more than 2 standard drinks on any given day

40
Q

Guidelines for Drinking Alcohol: Reducing risk of injury while drinking?

A

Drink no more than 4 standard drinks on any one occasion

41
Q

Guidelines for Drinking Alcohol: Young people < 18 years old?

A

Avoid alcohol if under 18 is the safest option

42
Q

Guidelines for Drinking Alcohol: Pregnancy and Breastfeeding?

A

Avoid alcohol is the safest option

43
Q

Alcohol Use Disorder - How is it Managed?

A
  • 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
Q

Alcohol Withdrawal - What are the 2 Ways it’s managed?

A
  • 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
Q

Alcohol Withdrawal

  • What is the onset?
  • In severely dependent drinkers?
A
  • Onset is usually 6-24 hours after last drink
  • In severely dependent drinkers, reducing alcohol intake may precipitate withdrawal even if still drinking
46
Q

Managing Alcohol Use Disorder – Withdrawal Seizures

  • When do they occur?
  • What are the types of seizures?
A
  • Occur early (7-24 hour post last drink)
  • Generalised seizures, usually single episode
47
Q

Managing Alcohol Use Disorder – Delirium Tremens

  • What can it cause?
  • Is it an emergency?
  • When do the symptoms occur?
  • What are the clinical features?
A
  • 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
Q

Managing Alcohol Use Disorder – Wernicke-Korsakoff Syndrome

  • Cause?
  • If not treated?
  • Signs?
A
  • 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
Q

Benzodiazepines in Alcohol Withdrawal

  • Are they used?
  • First line? reduce, avoid?
  • IV?
  • Oxazepam?
A
  • 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
Q

Other Medications Used During Alcohol Withdrawal?

A
  • Standard to commence a multivitamin
  • May also require:
    • Other anticonvulsants short term (e.g. CBZ, phenytoin)
    • IV fluids
    • Anti-emetics
    • Antipsychotics
    • Simple analgesics
51
Q

What are the 2 aims in Managing Alcohol Dependence?

A
  • 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
Q

There are 2 types of meds used in managing alcohol dependence.

What are they and what are their role?

A
  • 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
Q

Meds used in managing alcohol dependence: Disulfram

  • MOA?
  • Leads to?
  • Symptoms developed depend on?
  • When to commence?
  • Avoid alcohol for?
A
  • 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
Q

Meds used in managing alcohol dependence: Acamprosate

  • What does it reduce and prolong?
  • When to commence?
  • Adverse effects?
A
  • 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
Q

Meds used in managing alcohol dependence: Naltrexone

  • What does it reduce?
  • How does it work?
  • Monitor?
  • Adverse effects?
A
  • 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
Q

Other Drugs used for Managing Alcohol Dependence

A
  • Baclofen
  • Ondansetron
  • Topiramate
  • Prazosin
57
Q

Managing Alcohol Use Disorder During Pregnancy

A
  • Alcohol has harmful effects on the foetus
  • Foetal Alcohol Spectrum Disorder
  • Withdrawal increases risk of spontaneous abortion and pre-term delivery
58
Q

Problematic Benzodiazepine Use

  • Is dependence common?
  • What to encourage?
A
  • 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
Q

Is Benzodiazepine Overdose Life-Threatening?

A
  • Not usually life threatening
  • Risk increase when combined with opioids and/or alcohol
60
Q

What is used to treat Benzo overdose?

A
  • Flumazenil
    • Competitive GABA antagonist, reversal agent
61
Q

What influences withdrawal timeline of benzodiazepines?

A

Half-life of benzodiazepines vary substantially; some have active metabolites which influences withdrawal timeline

62
Q

How is Benzodiazepine Withdrawal Managed?

A
  • 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
Q
  • THC is metabolised by?
  • Can dependence develop?
  • What can be prescribed during withdrawal?
  • Cannabis use may increase likelihood of what diagnosis?
A
  • 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
Q

What are the 3 Stimulants?

A
  • Amphetamines
  • Cocaine
  • MDMA
65
Q

What are the Forms of Metamphetamine and their relative potencies?

A
  • Crystal – medium to high potency (usually most potent)
  • Base – medium to high potency
  • Powder – low to medium potency
66
Q

Methamphetamine Induced Psychosis is what?

What are the Types of Symptoms?

A
  • Serious potential side-effect of heavy methamphetamine use
  • Types of Symptoms
    • Paranoia and hallucinations
    • Can be mild to severe
67
Q

Amphetamine withdrawal - Are meds effective?

A

No meds shown to be effective, benzos may reduce irritability

68
Q

Cocaine Withdrawal

What is it effective?

What can cocaine dependence respond to?

A
  • Cognitive behavioural therapy effective
  • Cocaine dependence may respond to disulfram
69
Q

MDMA Withdrawal

  • Is overdose fatal?
  • What are the most significant toxic effects?
  • Treatment is?
A
  • Overdose may be fatal
  • Hyperthermia and hyponatraemia are the most significant toxic effects
  • Treatment includes reducing temperature, correction of fluid and electrolytes
70
Q

MDMA

  • Does it follow linear PK, where is it metabolised?
  • What are the drug interactions?
A
  • Non-linear PK, 80% metabolised in liver
  • Drug interactions with CYP2D6 or CYP3A4 inhibitors (+ serotonergic agents)
71
Q

Serotonin Syndrome and Illicit Drugs

  • What changes?
  • Caused by?
  • What drugs?
A
  • 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
Q

Pharmacological Treatments Available that have shown to assist smoking cessation – should be recommended to all patients interested in quitting

What are they?

A
  • Nicotine Replacement Therapy (NRT)
  • Varenicline (Champix)
  • Slow release bupropion (Zyban SR)
  • Nortriptyline
73
Q

Nicotine Replacement Therapy

  • What is it?
  • Can you used more than 1?
  • How long should it be continued for?
  • Pharmacokinetics?
  • Smoking increases ability to?
A
  • 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
Q

How does Varenicline work?

A
  • Partial agonist at alpha-4-beta-2 nicotinic receptor
  • Blocks nicotine prevents reward from smoking and partially activates receptor to minimise nicotine withdrawal
75
Q

What are the Adverse Effects of Varenicline?

When can people smoking until?

A
  • Nausea, dyspepsia
  • Stop smoking week 2
76
Q

Bupropion for Smoking Cessation

  • When is it started?
  • Duration?
  • Caution?
  • Can cause?
A
  • 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
Q

Nortriptyline for Smoking Cessation

  • MOA?
  • Commence treatment?
  • A/Es?
A
  • 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
Q
  • What are Vaping Devices?
  • Is nicotine approved by TGA?
  • Is nicotine legal?
A
  • 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

Pharmacotherapeutics Theory 2 (17 decks)

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