CNS substance dependence

Question 1

tx for MILD alcohol dependence

Answer 1

Do not need assisted alcohol withdrawal

Question 2

tx for MODERATE alcohol dependence

Answer 2

Treated in a community setting, unless high risk of developing alcohol withdrawal seizures/delirium

Question 3

tx for SEVERE alcohol dependence

Answer 3

Undergo withdrawal in an inpatient setting

Question 4

what drug class used to reduce alcohol withdrawal symptoms

Answer 4

A long-acting benzodiazepine eg chlordiazepoxide/ diazepam

(alternative: carbamazepine/clomethiazole)
only use clomethiazole if pt will stop dirnking else, esp in patients with cirrhosis, can lead to fatal respiratory depression even with short-term use.

Question 5

what to do when managing withdrawal from co-existing benzodiazepine and alcohol dependence

Answer 5

increase benzo dose

and use single benzo chlordiazepoxide/ diazepam

Question 6

If alcohol withdrawal seizures occur, what should be prescribed to reduce the likelihood of further seizures?

Answer 6

fast acting benzo eg lorazepam.
unlicensed

Question 7

In patients with delirium tremens (agitation, confusion, paranoia, and visual and auditory hallucinations), what is first line tx?

Answer 7

oral lorazepam
…
then parenteral lorazepam/ haloperidol

Question 8

ALCOHOL DEPENDENCE tx?
first line
second line
alternative?

Answer 8

CBT first then
Acamprosate/Naltrexone (alternative: disulfram)

Question 9

(what drug recommended for reduction of alcohol consumption in pt with alcohol dependence w high drinking risk level, without physical withdrawal symptoms, and who do not require immediate detoxification)

Answer 9

Nalmefene

Question 10

ALCOHOL DEPENDENCE

WERNICKE’S ENCEPHALOPATHY TREATMENT?

Answer 10

Thiamine (Vitamin B1)

bc pts w chronic alcohol use burn thru Thiamine stores in liver when metabolising alcohol, thiamine given to replenish stores and reduce toxicity

Prophylactic oral thiamine should also be given to harmful or dependent drinkers if they are in acute withdrawal, or before and during assisted alcohol withdrawal

Question 11

2 drugs for nicotine dependence?

Answer 11

varenicline
bupropion

Question 12

VARENICLINE should be avoided in which conditions?

Answer 12

Avoid in epilepsy/cardiovascular disease/psychiatric illness eg depression

currently unavailable in UK
but its a nicotine receptor blocker - stops feeling effects of smoking thus reducing want to smoke. no longer satisfying

Question 13

BUPROPION should be avoided in which pts?

Answer 13

Avoid in psychiatric illness/seizures/eating disorders

Question 14

bupropion can cause what syndrome

Answer 14

serotonin syndrome

Question 15

NICOTINE-REPLACEMENT THERAPY (NRT)?

Answer 15

Use a patch (16-hr if pregnant/nightmares) AND
Use a short-term reliever: lozenges/gum/sublingual tablets/inhalator/nasal/oral spray

otc

Question 16

tx for opioid dependence should be started by whom

Answer 16

approp qualified prescriber. not just a normal dr

Question 17

OPIOID DEPENDENCE

Prescribed on what form and max duration/ supply?

Answer 17

FP10MDA-> max. supply of 14 days

Question 18

OPIOID DEPENDENCE
when to refer back to specialist
hm missed doses?

Answer 18

3 or more
Risk of OD, loss of toleranace, consider reducing dose, refer to specialist

Question 19

t/f opioid dependence tx should be continued in pregnancy?

Answer 19

true
risk of not taking it through preg is much greater than risk of taking it

Question 20

what drug can be presc if opioid dependence tx at high risk of OD?

Answer 20

naloxone

Question 21

which is LESS sedating: buprenorphine/ methadone?

Answer 21

buprenorphine

Question 22

buprenorphine has milder withdrawal symptoms meaning what and why?

Answer 22

lower risk of OD
bc its a partial agonist

Question 23

buprenorphine tx, what drug given when there is a risk of injecting?

Answer 23

suboxone (buprenorphine with naloxone)

Question 24

OPIOID DEPENDENCE

METHADONE causes what? and must thus be titrated to pts needs?

Answer 24

Causes QT prolongation

Question 25

Untreated heroin dependence shows early withdrawal symptoms within X hr and peak symptoms at Y hrs?

Answer 25

within 8 hours, with peak symptoms at 36–72 hours. symptoms subside substantially after 5 days. Methadone hydrochloride or buprenorphine withdrawal occurs later, with longer-lasting symptoms.

Question 26

Complete withdrawal from opioids usually takes up to X weeks in an inpatient or residential setting, and up to Y weeks in a community setting

Answer 26

4 12

Question 27

Patients dependent on high doses of opioids may be at increased risk of precipitated withdrawal. Precipitated withdrawal can occur in any patient if buprenorphine is administered when other opioid agonist drugs are in circulation. Precipitated opioid withdrawal, if it occurs, starts within 1–3 hours of the first buprenorphine dose and peaks at around 6 hours. Non-opioid adjunctive therapy, such as lofexidine hydrochloride, may be required if symptoms are severe. To reduce the risk of precipitated withdrawal, the first dose of buprenorphine should be given when the patient is exhibiting signs of withdrawal, or 6–12 hours after the last use of heroin (or other short-acting opioid), or 24–48 hours after the last dose of methadone hydrochloride. It is possible to titrate the dose of buprenorphine within one week—more rapidly than with methadone hydrochloride therapy—but care is still needed to avoid toxicity or precipitated withdrawal; dividing the dose on the first day may be useful.

Question 28

why are pts titrated up on methadone?

Answer 28

long half-life, plasma concs progressively rise during initial treatment even if pt remains on same daily dose (takes 3–10 days for plasma concs to reach steady-state in pts on stable dose); a dose tolerated on first day of tx may become a toxic dose on third day as cumulative toxicity develops.

Question 29

Many pregnant patients choose a withdrawal regimen, but withdrawal from opioid sub therapy during the first trimester should be avoided why

Answer 29

increased risk of spontaneous miscarriage. fetal death

Question 30

The neonate should be monitored for what if the mother is prescribed high doses of opioid substitute.

Answer 30

respiratory depression and signs of withdrawal

Question 31

Signs of neonatal withdrawal from opioids usually develop X after delivery but symptoms may be delayed for up to 14 days, so monitoring may be required for several weeks.

Answer 31

24–72 hours

Question 32

symptoms of opioid withdrawal in neonate

Answer 32

high-pitched cry, rapid breathing, hungry but ineffective suckling, and excessive wakefulness; severe, but rare symptoms include hypertonicity and convulsions.

Question 33

Adjunctive therapy may be required for the management of opioid withdrawal symptoms. what drug used for... - diarrhea - stomach cramps - muscular pains + headaches - nausea/ vom - muscle pain assoc w methadone - insomnia

Answer 33

- loperamide - mebevrine - paracetamol, nsaids - metoclopramide/ prochlorperazine - Topical rubefacients - short-acting benzodiazepines or zopiclone

Question 34

what drug may alleviate some of the physical symptoms of opioid withdrawal by attenuating the increase in adrenergic neurotransmission that occurs during opioid withdrawal

Answer 34

Lofexidine

Question 35

complete