Addiction & Toxidromes Flashcards
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
INTOXICATION/OVERDOSE
Sx:
— cardiovascular effects
- tachycardia
- hypertension
- arrhythmias
- QT prolongation/QRS widening (with cocaine)
— central nervous system (CNS) excitation
- euphoria, agitation, restlessness
- delirium
- seizures
— neuromuscular features
- hyperreflexia
- tremor
— autonomic effects
- hyperthermia
- diaphoresis
- flushing
- pallor
- mydriasis
— gastrointestinal effects
- nausea, vomiting, diarrhoea.
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
INTOXICATION/OVERDOSE
Sedation
1 DIAZEPAM IV
OR
1 MIDAZOLAM IV
OR
1 DIAZEPAM VO
OR
1 HALOPERIDOL IV/IM ((in difficult cases))
The main treatment for overdose with stimulant drugs is sedation with IV BZs for CNS excitation, tachycardia, hypertension, hyperpyrexia and sympathomimetic stimulation (producing complications such as hyperthermia).
VO benzodiazepines may be used in patients with mild to moderate agitation if they are cooperative.
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
INTOXICATION/OVERDOSE
Anticonvulsant therapy
1 DIAZEPAM IV
OR
1 MIDAZOLAM IV
If intravenous access is not possible, use:
1 DIAZEPAM rectally
OR
1 MIDAZOLAM IM
Benzodiazepines should be used as the primary anticonvulsant in overdose patients if seizures are not self-limiting within minutes
Higher doses than for sedation are required
NOTE: Phenytoin is ineffective for drug-induced seizures and drug withdrawal, and should not be used because it blocks sodium channels and may increase the risk of arrhythmias.
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
INTOXICATION/OVERDOSE
Hypertension Mx:
If hypertension persists despite CNS sedation
1 glyceryl trinitrate IV infusion,
OR
2 sodium nitroprusside IV infusion
These are short-acting vasodilators
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
INTOXICATION/OVERDOSE
SVT Mx:
If there is no response to BZs
1 ADENOSINE IV
OR
2 VERAPAMIL IV
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
when to treat QRS widening
A normal QRS should be less than 0.12 seconds (120ms)
When QRS widening is associated with:
- any deterioration in mental status
- decompensation in airway, breathing or circulation (eg arrhythmias, hypotension)
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
QRS widening Mx
treatment is similar in QRS widening caused by opiod poisoning
sodium bicarbonate
PLUS
hyperventilation therapy (by intubation and mechanical ventilation)
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
Cocaine-related QRS widening Mx
Lidocaine IV
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
QT prolongation Mx
treatment is similar in QT prolongation caused by opiod poisoning
- if Hypomagnesaemia
magnesium sulfate - if Hypokalaemia
potassium chloride - if Hypocalcaemia
calcium gluconate
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
INTOXICATION/OVERDOSE
Decontamination
- There is almost no role for decontamination in stimulant drug toxicity and there is significant risk and difficulty inadministering it.
- In rare cases, when patients present early (within 1 hour after ingestion) and their clinical status
allows them to protect their airway, activated charcoal may be considered
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
Withdrawal Sx:
- hypersomnia
- hyperphagia
- irritability and aggression
- depression (low energy, low mood, apathy)
- craving
No medication has been shown to be particularly effective in the treatment of amphetamine withdrawal.
Benzodiazepines may be useful to reduce irritability. Antidepressants may be helpful for treatment of depression
arising from stimulant withdrawal.
ADDICTION/SUBSTANCE ABUSE
‘Stimulants’
Dependence Mx:
- little conclusive evidence on the effectiveness of pharmacotherapeutic interventions
- psychological interventions, such as CBT
ADDICTION/SUBSTANCE ABUSE
‘Opioids’
Intoxication/overdose
Sx:
“ARMED Colonialist”
A - Analgesia (reduced pain perception)
R - Respiratory depression
M - Myosis
E - Euphoria
D - Drowsiness (stuporous/comatose)
C - Constipation
ADDICTION/SUBSTANCE ABUSE
‘Opioids’
Intoxication/overdose
Decontamination
There is no absolute indication for any form of decontamination in opioid overdose
Activated charcoal is never indicated for short-acting opioids.
- the risk of sedation and aspiration, and the availability of an effective and easily administered antidote (naloxone), opioid toxicity can be managed with naloxone or with respiratory supportive care.
- For METHADONE (a long-acting opioid), activated charcoal may be considered if it can be administered within **1 hour **of the estimated time of ingestion to a cooperative, nonsedated patient
- For SLOW-RELEASE preparations overdose, activated charcoal may be considered if it can be administered within 6 hours of the estimated time of ingestion to a cooperative, nonsedated patient
ADDICTION/SUBSTANCE ABUSE
‘Opioids’
Intoxication/overdose
Antidote
Naloxone IV
opioid antagonist
ADDICTION/SUBSTANCE ABUSE
‘Opioids’
Withdrawal
Sx:
– Muscle aches
– Headaches
– seizures (if taking high doses)
– Hyperventilation
– Mydriasis
– Dysphoria
– Insomnia
– Fever
– Sweating
– Nausea and vomiting
– Stomach pains
– Diarrhoea
– Craving
- peak 2-3 days
- resolve within 5-7 days
ADDICTION/SUBSTANCE ABUSE
‘Opioids’
Withdrawal
Rx:
Buprenorphine VO (Sub-lingual)
ADDICTION/SUBSTANCE ABUSE
‘Opioids’
Dependence
Rx:
- psychosocial interventions (such as counselling, cognitive behavioural therapy, social support)
\+
- Methadone
OR
- Buprenorphine
(it is a partial agonist it has a lower risk of overdose and physical dependence compared to methadone; however, the lower agonist activity is not suitable for some patients)
Opioid dependence may present covertly in a general hospital setting when there is intercurrent illness in an opioid-dependent person. These patients may need to be administered an opioid during admission to prevent opioid withdrawal symptoms.
➜ Use buprenorphine as for treatment of withdrawal
In Australia, most detoxification provided to heroin-dependent persons is provided in rehabilitation centres.
Detoxification is often followed by cognitive-behavioural therapy, psychotherapy and counselling for the patient.So
this the best advice.
ADDICTION/SUBSTANCE ABUSE
‘Benzodiazepines’
Overdose/Poisoning
Sx
— CNS effects
* drowsiness
* sedation
* coma
* respiratory depression
— cardiac effects
* bradycardia and hypotension (with very
large overdoses)
— other effects
* hypothermia (with very large overdoses)
BENZODIAZEPINE HAVE NO SYMPATHOMIMETIC EFFECT (NO PUPIL DILATION/CONTRACTION
ADDICTION/SUBSTANCE ABUSE
‘Benzodiazepines’
Overdose/Poisoning
MX
FULL RECOVERY IS EXPECTED
with good supportive care.
Elderly patients and those with significant respiratory disease are more at risk of complications.
Supportive treatment if required
- Airway & breathing = hypoventilation -» monitor alkalosis, oxygen normally not necessary
- Circulation = hypotension -» fluid resuscitation
-
ADDICTION/SUBSTANCE ABUSE
‘Benzodiazepines’
Overdose/Poisoning
Decontamination
There is no indication for activated charcoal
in benzodiazepine overdose
due to the rapid onset of sedation and good outcome with supportive care
ADDICTION/SUBSTANCE ABUSE
‘Benzodiazepines’
Overdose/Poisoning
Antidote
FLUMAZENIL
(It has little role in managing benzodiazepine overdose)
TIP: Only Clobazam can be individually identify on urine drug testin
(it has a duration of action of approximately 45 to 60 minutes, after which time re-sedation may occur because most benzodiazepines have a much longer duration of action)
ADDICTION/SUBSTANCE ABUSE
‘Benzodiazepines’
Overdose/Poisoning
Indications of use of Flumazenil
— ELDERLY or other patients with respiratory disease (eg COPD) where intubation should be avoided, as CNS depression with poor respiratory effort and poor cough may result in atelectasis and respiratory infection
— in the TREATMENT of CNS DEPRESSION due to iatrogenic over-treatment with benzodiazepines (eg in procedural sedation), where short-term use of flumazenil may be beneficial
— unintentional lone paediatric benzodiazepine ingestion with compromised airway and breathing
— benzodiazepine overdose resulting in compromised airway or breathing in settings where resources for
intubation are not available.
ADDICTION/SUBSTANCE ABUSE
‘Benzodiazepines’
Withdrawal/discontinuation Sx
manifestations of sympathetic hyperactivity:
- anxiety
- insomnia
- irritability
- myoclonic jerks
- palpitations
- hypertension
- sensory disturbances such as hyperacusis and
photophobia - Abrupt discontinuation in patients taking high doses (eg greater than 50 mg diazepam daily or
equivalent) may be accompanied by seizures - Hallucinations
MX: Diazepam
Benzodiazepines, like alcohol, exert their inhibitory effects via GABA receptors, and their sudden withdrawal leads to an excitatory state. Sudden discontinuation can lead to withdrawal symptoms within
24-48 hours; withdrawal symptoms from long-acting benzodiazepines may develop over a more protracted period.
ADDICTION/SUBSTANCE ABUSE
‘Benzodiazepines’
DEPENDENCE Mx:
Patient may be allowed to continue Hypnotic if:
1-Patient is be aware of dependence
2-There is no history of any adverse event or adverse side effect from that medication.
3-Reduction program has been unsuccessful If
ADDICTION/SUBSTANCE ABUSE
‘Cannabis’
Intoxication/Overdose
Sx
- sedation
- euphoria
- increased appetite
- elevated heart rate
- reddening of the eyes
- cognitive (including memory loss) and psychomotor impairment
- altered time perception.
ADDICTION/SUBSTANCE ABUSE
‘Cannabis’
Harmful side effects of chronic use
– Chronic cough (not COPD)
– Increased risk of stroke and heart disease
– Poorer academic achievement
– Increased risk of suicide attempts
– Drug-induced Psychosis
– Increased risk of development of psychotic illness (schizophrenia, most common)
ADDICTION/SUBSTANCE ABUSE
‘Cannabis’
Dependence
Mx
- CBT
There is no evidence for pharmacological treatment of cannabis withdrawal or relapse prevention
