Drug Misuse Flashcards
criteria for opioid intoxication include:
1) recent use of an opioid
2) clinically significant problematic behavioral or psychological changes (euphoria followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgment, or impaired social or occupational functioning) that develop during, or shortly after, opioid use
3) pupillary constriction (or pupillary dilation from severe overdose) and one or more of the following signs: drowsiness or coma, slurred speech, and impairment in attention or memory
4) and the symptoms are not due to a general medical condition or another mental disorder.
The classic “triad” of opioid overdose consists of respiratory depression, pinpoint pupils (miosis), and coma.
Features of alcohol intoxication
There will be cerebral degeneration
slurred speech
impairments in memory and judgment.
unsteady gait - ataxia
nystagmus.
Chronic back ache what are non opioid will be helpful and what will not.
Things will be helpful
1)NSAIDs
2) Duloxetine, an SNRI
3) Acupuncture
Not helpful
1) acetaminophen
2)tricyclic antidepressants
(TCAs)
3) selective serotonin reuptake inhibitors (SSRIs)
4) Gabapentin (and pregabalin)
5) TENS units
Chronic , non cancerous pain - what pain med is more recommended?
nonopioid medications over opioid analgesics in all patients but particularly in patients with substance use disorders
opioid withdrawal signs
dysphoric features
diarrhea
fever
Within 24h
muscle aches
restlessness/ anxiety
watering eyes/ runny nose - lacrimation or rhinorrhea
excessive sweating
yawning
inability to sleep
• Later
Diarrhoea abdominal cramps goosebumps (‘cold turkey’) - piloerection nausea/ vomiting blurred vision dilated pupils tachycardia i BP
When to start buprenorphine in withdrawal
when patients are exhibiting early signs of withdrawal.
For short-acting opioids (e.g., heroin, oxycodone) this may be 12 hours after the last use
longer-acting opioids such as methadone, withdrawal symptoms may not manifest until 48 hours after last use.
After how many hours does the withdrawal symptoms start in short and long acting opioids
For short-acting opioids
(e.g., heroin, oxycodone)
12 hours after the last use
longer-acting opioids such as methadone
48 hours after last use.
Typical frist day dose of buprenorphine?
The first day dose should be 4 mg and patients should be monitored for withdrawal symptoms for 2 to 4 hours, with the opportunity to administer an additional dose (up to 8 mg in the first day).
Y is Combination buprenorphine/naloxone preferred over buprenorphine monotherapy
Due to lower abuse potential, unless a patient is pregnant, lactating, or allergic to naloxone
Can Naloxone given to pregnant ?
No
After initiation the buprenorphine dose , how should it be titrated to relieve withdrawal symptoms
After initiation, the buprenorphine dose should be titrated to relieve withdrawal symptoms by doubling the previous total daily dose plus adding 2 to 4 mg.
Most patients will stabilize on 8 to 16 mg daily;
however, some may require doses up to 32 mg daily, which is the maximum dosage
advantages of buprenorphine over methadone ?
advantages of buprenorphine over methadone are that it can be dispensed at a physician’s office with an appropriate Dea waiver which requires the ability to provide or refer the patient for counseling, unlike methadone, which can only be dispensed at designated treatment centers. because of its partial agonist action, buprenorphine has a “ceiling effect” with regard to overdose making it safer than methadone; whereas, methadone produces increasing respiratory suppression with increasing doses. Suboxone is a patented combination of buprenorphine and naloxone that requires a physician to obtain a special “X” Dea number in order to prescribe.
Alcohol withdrawal features
tachycardic
hypertensive
febrile
diaphoresis. - sweating unusually
tremors
vomiting
hallucinations.
Dx criteria for alcohol withdrawal
1) cessation or reduction of a previously heavy alcohol intake
2) at least two of the following within hours or days: autonomic hyperactivity (hypertension, sweating, tachycardia, etc.), hand tremor, insomnia, nausea/vomiting, hallucinations, agitation, anxiety, grand mal seizures.
3) one must have significant distress or impairment in functioning with the withdrawal and no other illness causing the symptoms.
Which class of drugs would you choose to treat the symptoms of alcohol withdrawal??
How does it help
Benzodiazepines
It decreases physical distress and to prevent major withdrawal (e.g., delirium tremens) from occurring.
Alcohol and vitamins
the traditional “banana bag” of iV multivitamins is unnecessary.
oral vitamin supplements are just as effective and less expensive.
People with chronic alcohol dependence are frequently deficient in vitamins, especially thiamine. (B2 )give oral thiamine indefinitely (if severe, 200– 300mg/ d; if mild, 10– 25mg/ d). During detoxification in the community— give thiamine 200mg od for 5– 7d.
Cage questionnaire
The “CAGE” questionnaire is a very brief and useful screening tool, employed effectively in the primary care setting.
A positive answer to two or more questions is very sensitive and specific for an alcohol use disorder. It consists of asking the patient the following four questions: Have you ever
- C: felt that you should Cut Down on your drinking?
- A: been Annoyed that people criticized your drinking?
- G: felt bad or Guilty about your drinking?
- E: taken a drink first thing in the morning (Eye Opener) to get rid of a hangover or steady your nerves?
What is alcohol tolerance
the need for increasing amounts of a drug to achieve the same response as initial use of the drug.
What is intoxication
syndrome of maladaptive behavior or psychological changes that occur with substance use, is drug-specific, and reverses when the drug use is discontinued
Lab finding of a alcoholic
⬆️ GGT highly sensitive , but not specific
⬆️ ALT and AST
AST:ALT ratio is 2:1
⬆️ bilirubin
macrocytic anemia , MCV ⬆️
⬆️ serum triglycerides
hypoglycemia
⬆️ Ferritin in active alcohol users in the absence of iron overload
the transferrin saturation may be elevated because alcohol inhibits transferrin synthesis.
USS— fatty liver/ cirrhosis
Which drug would be indicated to prevent delirium tremens (DT) in a patient with hepatic impairment?
Benzodiazepines that are metabolized by the cytochrome P450 system will build up in the presence of liver disease, so using those with intermediate half-lives and no active metabolites is essential.
So below drugs meet these criteria
lorazepam
oxazepam
temazepam
Alprozolam cannot be used. Coz it is very short acting
Is delirium tremor common in alcohol withdrawal person
Which type of hallucinations is common
Can it be confused with dementia
After stopping alcohol after how long DT occurs
No. Only 3 to 5%
Visual and tactile
No coz dementia - the cognitive decline is over a course of months to years
2 -3 days. 72 hours
S/S of delirium toxicity
General Fever
Autonomic instability
- tachycardia
- Increase BP,
- Increase respiratoryrate
Psychiatric Visual/ tactile hallucinations
acute delirium
apprehension
Neurological Tremor
fits
fluctuating level of consciousness
Which medication would be the best choice for DT in a patient who is vomiting profusely and who has no IV access?
Lorazepam
It is absorbed well intramuscularly and can also be provided IV
the iV form of lorazepam can also be administered sublingually to speed absorption if you want to use an oral medication. obviously iV is even faster yet (if you have access).
