Alcohol and Drug Dependence Flashcards
What is alcohol dependence?
A cluster of behavioural, cognitive and physiological factors that typically include a strong desire to drink alcohol, tolerance to its effects and difficulties controlling its use.
Assisted Alcohol Withdrawal
-A long-acting benzodiazepine such as chlordiazepoxide or diazepam is recommended to reduce alcohol withdrawal symptoms
-Fixed-dose reducing regimens often used in primary care- using an initial dose followed by a dose reduction to zero.
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What is delirium tremens?
A medical emergency that requires specialist inpatient care.
- Agitation, confusion, paranoia, hallucinations.
-Oral lorazepam is first-line, parenteral lorazepam or haloperidol can be given if oral is declined or symptoms persist.
Alcohol Dependence
-Harmful drinkers or mild dependence, CBT should be offered. Acamprosate calcium or naltrexone can be used alongisde psychological interventions.
-Acamprosate and naltrexone combined with psychological interventions for moderate and severe alcohol dependence. Disulfiram can be used if the patient understands the risks.
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Wernicke’s Encephalopathy
- Parenteral thiamine, followed by oral thiamine should be given to patient’s who are suspected to have this condition
-Higher risk if malnourised, or have decompensated liver disease.
Heroin Dependence:
-Withdrawal symptoms usually kick-in within 8 hours of not using, peak symptoms at 36-72 hours.
-Symptoms substantially subside after 5 days.
-Methadone and buprenorphine withdrawal occurs later, with longer-lasting symptoms.
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Opioid Substitution Therapy
-Methadone or Buprenorphine
-A withdrawal regiment after stabilisation with OST should be attempted after careful consideration: if abstinence not achieved or illicit drug use is resumed, resume maintenance therapy at optimum dose.
-After successful withdrawal treatment, continue further support and monitoring for a period of at least 6 months.
If a patient misses _ days or more of their regular prescribed dose of opioid maintenance therapy, they are at risk of overdose due to loss of tolerance. Consider restarting on lower dose.
-If 5 or more days missed, assess illicit drug use before restarting substitution therapy.
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Buprenorphine
-Less sedating than methadone
-Safer than methadone in overdose
-Milder withdrawal symptoms than methadone.
Patients dependent on high opioid doses have an increased risk of precipitated withdrawal- can occur if patient takes buprenorphine when other opioid agonist drugs are still in circulation.
Reduce risk:
-First buprenorphine dose should be given 6-12 hours after last heroin dose, or when pt is exhibiting withdrawal. Or 24-48h after last methadone dose.
How can you reduce the risk of precipitated withdrawal in patients on buprenorphine OST?
Patients dependent on high opioid doses have an increased risk of precipitated withdrawal- can occur if patient takes buprenorphine when other opioid agonist drugs are still in circulation.
Reduce risk:
-First buprenorphine dose should be given 6-12 hours after last heroin dose, or when pt is exhibiting withdrawal. Or 24-48h after last methadone dose.
Methadone
-Has a more pronounced sedative effect than buprenorphine- may be preferred in patients with a long history of opioid abuse or patients who typically abuse sedative drugs.
-Initiate at least 8 hours after last heroin dose.
-Titration to optimal dose may take several weeks.
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OST During Pregnancy
-Acute withdrawal of opioids should be avoided in pregnancy
-OST recommended in pregnancy- continue on the drug they have been stabilised on.
-Avoid withdrawal regimen in first trimester- risk of miscarriage- withdrawal should be undertaken gradually in second trimester.
-Do NOT continue further withdrawal in third trimester- maternal withdrawal increases fetal distress, stillbirth and neonatal mortality.
-Drug metabolism increases in third trimester: may require increase OST dose or twice-daily consumption to prevent withdrawal.
-In breastfeeding mothers, keep OST dose as low as possible and monitor babie for sleeplessness, breathlessness and limpness.
Methadone and SSRI’s
-SSRI’s can inhibit methadone metabolism, potentially causing methadone levels to rise and cause toxicity.
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Methadone Interactions
- OPIOIDS!!! (morphine, codeine, buprenorphine etc)
-Antidepressants, mainly MAOIs
-Benzodiazepines
-Antiemetics
-HIV medications
-Epilepsy medications
-AF medications
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REMEMBER: Methadone does not affect the effectiveness of any contraceptive method. However, if you vomit due to methadone, your contraceptive pills may not protect you.
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What are some potential side-effects of methadone?
-COnstipation
-Nausea and vomiting
-Sleepiness
-Headache
-Feeling cold and sweating more than usual
-Dry eyes, mouth and nose
-Hallucinations
