Addiction Pharmacology

Question 1

CAGE Screening

Answer 1

-yes to 1: signifies a potential problem & need for follow-up
yes to 2 or more: clinically significant
C: Have you ever felt the need to CUT DOWN on your drinking/drug use?
A: Have you ever been ANNOYED at criticism of your drinking/drug use?
G: Have you ever felt GUILTY about something you have done while drinking/taking drugs?
E: Have you ever had an EYE-OPENER - drinking or taking drugs first thing in the morning to avoid withdrawal symptoms?

Question 2

Alcohol

Answer 2

CNS depressant
MOA –> increases GABA receptor function
Intoxication –> slurred speech, incoordination, unsteady gait, nystagmus, stupor, coma
Withdrawal –> N/V, diarrhea, diaphoresis, elevated BP, anxiety, tremors, insomnia, delirium, seizures

Question 3

Naltrexone

Answer 3

Opioid antagonist; antidote
MOA –> blocks the mu-opioid receptor
Indication –> alcoholism & opioid/opiate addiction (decreases cravings & high of alcohol/drug)
Adverse effects –> nausea, headache, dizziness, loss of appetite, depression

Question 4

Depot Naltrexone (Vivitrol)

Answer 4

IM injection into gluteal area with 1.5 inch 20 gauge needle

• must be refrigerated (lasts 30 days)
• can cause necrosis of the skin (need to hit the muscle)
• patients should carry a safety card to alert people that in an emergency they need non-opioid pain management

Question 5

Acamprosate

Answer 5

GABA agonist/Glutamate antagonist
MOA–> modulation of glutamate transmission at metabotropic-5 glutamate receptors
Indication –> reduces the rate of patients returning to drinking; reduces tension, dysphoria, cravings associated with Alcohol abstinence
Dose –> usually 666mg TID unless bodyweight is less than 60kg
Adverse effects –> well-tolerated generally, may experience diarrhea, nervousness & fatigue but diminish over course
Nursing implication –> safe in liver disease patients but need to adjust dose in renal disease (contraindicated in renal failure)

Question 6

Disulfram

Answer 6

Aldehyde Dehydrogenase Inhibitor
MOA –> interferes with aldehyde dehydrogenase & therefore increases acetaldehyde levels, resulting in flushing, nausea, thirst, chest pain, palpitations that last 0.5-1 hours typically (experience these things if you drink while taking this med)
Adverse effects –> drowsiness, headache, fatigue, metallic or garlic-like aftertaste
Nursing implication –> don’t administer until patient has abstained for 12 hours; no mouthwash, cough syrups, vinegar, cider, extracts or other things that may contain alcohol

Question 7

Topiramate

Answer 7

Used off-label for alcohol withdrawal

• trial found that it may reduce consumption of alcohol
• makes patient’s drowsy & they get a high from it

Question 8

Gabapentin

Answer 8

Used off-label for alcohol withdrawal

-can reduce withdrawal symptoms including insomnia & anxiety (but does provide a high)

Question 9

Antidepressants

Answer 9

Used off-label for alcohol withdrawal

• helpful with comorbid depression to reduce alcohol intake
• predictors of response: later age of onset, psychosocial issues & low familial loading

Question 10

Clinical Institute Withdrawal Assessment (CIWA)

Answer 10

10 criteria scored on 0-7 scale

• Criteria: nausea, tremors, anxiety, agitation, sweats, sensorium, tactile, A/V disturbance, headache
• total the scores & follow the protocol for med administration (nursing assessment = important)
• also used for sedative/hypnotic withdrawal

Question 11

Alcohol Withdrawal Intervention

Answer 11

Pharm:
-long-acting benzodiazepine –> Valium, Ativan used in slow taper; like drug for like drug
-Thiamine –> prevent encephalopathy
-Folic Acid/Multivitamin –> correct deficiencies
-Magnesium sulfate –> reduce seizures
-Anticonvulsants –> control seizures
-PRNs to control nausea/BP/sleep
Non-pharm:
-supportive environment, low stress, clustered care, monitor VS

Question 12

Opioids

Answer 12

MOA –> bind to opiate receptors in the CNS causing inhibition of ascending pain pathways, altering the perception of and response to pain
Effect –> sense of contentment, miosis, parasympathetic nervous system activation; “nodding out,” dream-like state
Adverse effects –> respiratory depression, constipation, nausea, hypotension, anemia, death
Examples –> Hydrocodone, oxycodone, fentanyl, oxymorphone, methadone, tramadol

Question 13

Methadone

Answer 13

Analgesic, opioid
MOA –> binds to opioid receptors; half life is 8-59 hours (replaces one opioid for another, but with the long 1/2 life it prevents withdrawal & doesn’t cause immense euphoria)
Indication –> opioid dependence maintenance; chronic pain
Dose –> initiation at 20-30mg; maintenance at 80-120mg daily
Adverse effect –> respiratory depression, bradycardia, sedation, constipation
Nursing implication –> education surrounding 1/2 life & danger of mixing with other sedatives

Question 14

Naltrexone nursing implications

Answer 14

• make sure they have a “clean stream” (7-10 days clean)
• will precipitate withdrawals from opioids
• once on drug, patient can use opioids without precipitation of withdrawal (blunts the high)
• black box warning: hepatotoxicity

Question 15

Buprenorphine

Answer 15

Analgesic, opioid partial agonist
MOA –> high affinity for the mu opioid receptor
Indication –> chronic pain, maintenance therapy for opioid dependence (prevents opioid associated euphoria)
Adverse effects –> constipation, sedation, CNS depression, nausea
Nursing implication –> explain side effects & importance to not mix with other sedatives, reduce stigma & reassure patient

Question 16

Buprenorphine & Naloxone (Suboxone)

Answer 16

Analgesic, opioid; partial agonist; antagonist
MOA –> high affinity for the mu opioid receptor & opioid antagonist
Indication –> opioid dependency; induction of detox, opioid dependence maintenance therapy
Adverse effects –> precipitates withdrawals unless patient uses heroin after on maintenance therapy, constipation
Nursing implications –> don’t administer if patient hasn’t scored appropriately on COWS (if given too soon, will cause immediate, intense withdrawals)
-less likely to be abused than buprenorphine alone

Question 17

Naloxone

Answer 17

Use –> overdose antidote
Route –> endotracheal, IM, SubQ, Inhalation
Onset –> 2-18 minutes depending on route
Adverse effects –> precipitates withdrawals
Approved for use in pediatric population

Question 18

Clinical Opioid Withdrawal Scare (COWS)

Answer 18

11 Criteria scored on a 0-5 scale (range varies per criteria)

• criteria: HR, sweating, restlessness, pupil size, aches, lacrimation, rhinorrhea, GI, tremor, yawning, anxiety, goose flesh
• total the score & follow the protocol for admin of meds
• done every 4-6 hours (nursing assessment important)

Question 19

Opioid Withdrawal Intervention

Answer 19

Pharm:
-Valium or buprenorphine/Saboxone taper that lasts 5-7 days inpatient detox
-Clonidine for BP
-Phenergan for nausea
-Trazodone for sleep
Non-pharm:
-warm showers, low stress, emotional support, monitor VS

Question 20

Algorithm for Detox

Answer 20

Hierarchy of detox –> detox from sedative hypnotics or alcohol detox with CIWA monitoring trumps all; detox one substance at a time
Opioids & alcohol –> start with alcohol detox & CIWA monitoring, then add buprenorphine for opiate detox later
Alcohol & benzodiazepines –> detox patient from benzodiazepines (that will usually detox the patient from alcohol at the same time)
Benzodiazepines & opioids –> detoxify patient rom benzodiazepines, then add buprenorphine for opioid withdrawal later

Question 21

Nicotine

Answer 21

MOA –> binds to nicotinic-cholinergic receptors at the autonomic ganglia, in the adrenal medulla, neuromuscular junctions & the brain
Effect –> calming or excitation, increased concentration, agitation
Withdrawals –> restlessness, difficulty sleeping, irritability, craving, “Nic fit”
Examples –> smokeless “dip,” patches, gum, lozenge, cigarettes, cigar, vaporizer “juice,” inhalor

Question 22

Nicotine Replacement Therapy

Answer 22

Smoking cessation aid (gum, lozenge, patch, inhaler)
Adverse effects –> headache, mouth/throat irritation (inhaler), dyspepsia, rhinitis, dizziness
Nursing implications –> advise patient to completely stop smoking before therapy (otherwise you’re just increasing the amount of nicotine they’re receiving)

Question 23

Varenicline

Answer 23

Partial nicotine agonist
Indication –> smoking cessation
MOA –> partial nicotinic receptor agonist, prevents nicotine simulation of mesolimbic dopamine system
Adverse effects –> headache, insomnia, abnormal dreams, irritability, depression, flatulance
Nursing implications –> start one week before target quit date, if patient is successful in quitting within 12 weeks, may continue for 12 more & if not, stop therapy and reassess

Question 24

Marijuana

Answer 24

MOA –> activates cannabinoid receptors (CB1 & CB2)
Benefits –> analgesia, antiemetic, appetite induce; poor evidence/controversial
Adverse effects –> euphoria, abnormal thinking, dizziness, increased appetite
Withdrawals –> (no physical withdrawals, only psychological) anger, irritability, anxiety, restlessness, sleep difficulty, depressed mood
Long-term effects –> depression, motivational syndrome, psychosis, chronic anxiety
Nursing implications –> educate patient on potential long-term effects, withdrawals
No FDA approved treatment for dependence/abuse

Question 25

Dronabinol

Answer 25

Antiemetic, appetite stimulant (adult, geriatric & pediatric)
Indication –> appetite stimulation in AIDS patients, chemotherapy-induced N/V
MOA –> naturally occurring component of Cannabis Sativa plant, equal affinity for CB1 & CB2 receptors in CNS
Caution –> in persons with substance use disorder, mental health issues

Question 26

Drugs with possible off-label use for Cannabis Abuse

Answer 26

Baclofen –> decreased craving but didn’t effect relapse
Mirtazepine –> improved sleep in withdrawal but robust appetite increase
Atomoxetine –> improved cannabis-induced ADHD symptoms, reduced cannabis use & increased abstinence days
Buspirone –> greater percentage of cannabis-negative urine samples & happens more quickly