Alcohol, Opioids + Other Drugs B&B

Question 1

what % of untreated delirium tremens cases are fatal? what is a preceding sign? what is the cause of death?

Answer 1

delirium tremens (DTs) = severe alcohol withdrawal, ~20% untreated are fatal

preceded by seizure —> death due to autonomic instability

Question 2

what is the dopamine system that is active in brain reward/ substance abuse?

Answer 2

mesolimbic dopamine system - from ventral tegmental area (VTA) to nucleus accumbens (NA) to prefrontal cortex

Question 3

which of the following is NOT schedule IV?
a. ketamine
b. benzodiazepines
c. zolpidem

Answer 3

a. ketamine is schedule III

schedule I = high abuse potential, no medical use
schedule II = high abuse potential, medical use
schedule III = less potential
schedule IV = low potential
schedule V = lowest potential for abuse

Question 4

what is considered at risk drinking for men vs women?

Answer 4

men = 4+ drinks/day or 14/week

women = 3+ drinks/day or 7/week

Question 5

what is the CAGE criteria

Answer 5

C: ever felt you should cut down on drinking?
A: people are annoyed by your drinking?
G: ever felt guilty about your drinking?
E: have had an eye opener drink in the morning?

2 positive responses = positive test

Question 6

what is a really good lab marker for alcohol abuse?

Answer 6

GGT - liver function test that is very specific for heavy drinking (>35)

Question 7

what is the tx for alcohol withdrawal?

Answer 7

benzodiazepine taper (4-6 days) - prevent seizures, sedate patient so they’re more comfortable

antiseizures (carbamazepine, phenobarbital) can also be used, but won’t act as relaxants

+ fluid/ electrolytes (Mg+, K+)

Question 8

what is the MOA and clinical use of disulfiram?

Answer 8

aka Antabuse, treats alcohol use disorder

inhibits acetaldehyde dehydrogenase —> causes withdrawal symptoms due to accumulating acetaldehyde

Question 9

what are the 3 options for medication assisted treatment (MAT)?

Answer 9

1. methadone = agonist
2. buprenorphine (Suboxone) = partial agonist
3. naltrexone (Vivitrol) = antagonist

Question 10

to which receptors do endorphins vs enkephalins vs dynorphins bind?

Answer 10

endorphins —> mu R
enkephalins —> delta R
dynorphins —> kappa R

Question 11

what happens following activation of opioid receptors?

Answer 11

coupled to G proteins, binding causes:
1. closure of presynaptic Ca2+ channels —> reduce NT release
2. opening of postsynaptic K+ channels —> hyperpolarization

altogether causes decreased NT activity, esp. glutamate (major excitatory NT)

Question 12

which opioid does NOT cause miosis (small pupils)?

Answer 12

meperidine

Question 13

which opioid is most useful for the following problems?
a. acute pulmonary edema
b. cough suppression
c. diarrhea
d. shivering

Answer 13

a. acute pulmonary edema - IV morphine
b. cough suppression - codeine
c. diarrhea - loperamide
d. shivering (such as from infection, chemo) - meperidine (opioids cause skin flushing/warmth)

Question 14

what are 3 unusual effects of opioid withdrawal?

Answer 14

1. yawning
2. rhinorrhea/lacrimation
3. piloerection

Question 15

Pt presents to ED for drug withdrawal of unknown cause. Their nose and eyes are running, and the hair is standing up on their arms. They are also yawning frequently. What type of drug are they using?

Answer 15

opioids - withdrawal causes yawning, rhinorrhea/lacrimation, piloerection (among more obvious signs)

Question 16

which MAT is also used in alcohol abuse?

Answer 16

naltrexone: long-acting opioid antagonist, blocks effects of opioids if taken (prevents relapse)

Question 17

what is the treatment for PCP (phencyclidine, “angel dust”) intoxication? (2)

Answer 17

1. benzodiazepines - sedative
2. haloperidol - rapid-acting anti-psychotic

Question 18

what electrolyte imbalance can occur from ecstasy (MDMA) intoxication?

Answer 18

hyponatremia - NMDA causes increased fluid intake + secretion of ADH

may cause seizures/death

[MDMA = methylenedioxy-methamphetamine]

Question 19

what is the presentation (3) of and treatment (1) for serotonin syndrome?

Answer 19

triad: Agitation + Autonomic hyperactivity (hyperthermia, tachycardia, diaphoresis) + NMJ hyperActivity (tremor, clonus, hyperreflexia, bilateral Babinksi)

tx: cyproheptadine (5-HT antagonist)

Question 20

what is the MOA of morphine, oxycodone, hydrocodone, and fentanyl?

Answer 20

opioid full agonists at mu receptors

at presynaptic neuron, inhibit adenylyl cyclase-catalyzed formation of cAMP + close Ca2+ channels —> decrease NT release (esp. glutamate)

at postsynaptic neuron, open K+ channels —> hyperpolarization

Question 21

what is the medical use of fentanyl?

Answer 21

regional anesthesia + used for palliative care (80-100x more powerful than morphine)

Question 22

name 3 opioids which are NOT used for pain management that are full agonists at mu receptors

Answer 22

1. methadone - opioid detoxification and maintenance
2. codeine - cough suppressant
3. dyhydrocodeine - cough suppressant

Question 23

partial agonist at mu receptors

Answer 23

buprenorphine - combined with naloxone (Suboxone) or alone (Subutex) for opioid detoxification + maintenance

Question 24

name 3 mixed agonist-antagonists of opioid receptors and describe their MOA

Answer 24

1. pentazocine
2. nalbuphine
3. butorphanol

kappa agonist to produce analgesia; mu antagonist - treat mod-severe pain with decreased abuse potential (note, can precipitate withdrawal with antagonist activity)

Question 25

what is the MOA of pentazocine, nalbuphine, and butorphanol?

Answer 25

mixed opioid agonist-antagonists: kappa agonist to produce analgesia + mu antagonist

treat mod-severe pain with decreased abuse potential (note, can precipitate withdrawal with antagonist activity)

Question 26

naloxone vs naltrexone

Answer 26

both opioid antagonists at all receptors (mu, kappa, delta)

naloxone = NOT orally active, for acute opioid detoxification + prevent relapse

naltrexone = orally active, for relapse prevention

Question 27

what is the MOA and clinical use of diphenoxylate (Lomotril) and loperamide (Imodium)?

Answer 27

agonists at peripheral mu receptors - treat diarrhea

Question 28

what is the MOA and clinical use of methylnaltrexone (Relistor)?

Answer 28

antagonist of peripheral mu receptors —> treats opioid-induced constipation