Drugs of Abuse Flashcards
Opiate drug testing
Usual UDS’s test for?
What is the standard cutoff for testing?
- Tests for Codeine and Morphine metabolites usually
- Cutoff is 2000 ng/ml
What are the barriers to naloxone use?
- State law
- Physician liability
- Bystander liability
- fear of being prosecuted (bystander)
What are the only drugs that will show up on a normal opioid drug screen
- Heroin
- Codeine
- Morphine
- Hydromorphone
- Hydrocodone
What is the confirmatory test that is done if a patient preimptively tests positive for a substance?
Mass spec
Buprenorphine/ Naloxone? Advantages?
They cant shoot this up because it wont work due to the naloxone
Treatment of opioid intoxication or OD?
Naloxone max 10 mg
Your body has adapted to the medication and if you dont take it youll get withdrawals
Physical Dependence
Naltrexone for maintenance
- Must be detoxified prior to using
- Many compliance issues
- Monitor LFTs
- Vivitrol- monly IM injection
Consequence of IV opioids?
- Mood disorder, Dementia
- Infection, Endocarditis
- Disease, HIV, Hep, STD
- Overdose
Symptoms based treatment
Agitation?
Insomnia?
Headache, aches?
Abdominal cramps?
Diarrhea?
- Clonidine
- Diphenhydramine, Trazodone, Hydroxyzine
- NSAID, Acetaminophen
- Dicyclomine
- Bismuth subcarbonate
Treatment options and supportive care for AWS?
- Thiamine
- Folic Acid
- Magnesium
- Multivitamin
- Fluids
- Bananas bag- NS, Thiamine, Folic Acid, MVI
- Nonpharm
- Quiet environment, Reduced light
Effects of opiates?
- Mood changes/depression
- Drowsiness
- Inability to concentrate
- Flushing in face and neck
- Constipation
- N/V
- Respiratory depression
WHy is Rx drug abuse increasing?
- Consumer
- Industry
- Physician
- Society
Other OTC or Rx abused meds?
- Cough meds
- Synthetic drugs (K2, Spice)
Types of narcotics?
- Opium
- Morphine
- Codeine
- Hydromorphone
- Oxy
- Fentanyl
What are the symptoms of Karsakoff Psychosis?
- Psychosis
- Retrograde amnesia
- Confabulation
Why do people abuse opiates?
- Euphoric feeling
- Avoid emotional pain
- Avoid physical pain
- Supress withdrawal symptoms
What is the long acting benzo used for AWS?
Why could this potentially be harmful?
- Chlordiazepoxide
- Its metabolized in the liver but is very long acting this can pose problems due to decreased liver function in alcoholics
What increases the risk of developing alcohol withdrawal syndrome? 2 of them
- At least 3 months of daily alcohol consumption
- Consumption of large quantities for the past week
What increases your risk for Delirium Tremens (DT)
- Previous DT
- Hx of using equivalent to 1 pint of whiskey per day for the last 10-14 days
- Cirrhosis (enlarged liver)
- Early onset alcohol withdrawal
What are the common Rxs of abuse?
- Opiates
- Benzos
- Stimulants
Medications that can cause positive results for THC UDS
- Efavirenz
- Metabolite interferes with antibodies in immunoassay
- NSAIDs
- Conflicting studies
- Pantoprazole
- Dronabinol (Synthetic THC) Its a positive
What is naltrexones role in Alcohol Abstinence?
Been shown to reduce?
What to monitor?
- It may reduce the reward that is associated with drinking
- Been shown to reduce cravings, number of drinks, and relapse
- Monitor LFT
Detoxification?
- Methadone
- Bupronorphine
- Other opioids
- Symptomatic treatment (just when symptoms come up)
Before you interpret someones drug test you need?
- Detailed Med Hx
- Prescription
- OTC
- Herbal
- Documentation of last use
- Knowledge of which medications, metabolites can complicate accurate interpretation
A limitation of urine drugs tests?
That if someone has just smoked or used they must be given at least 2 hours before testing, otherwise the results will be inconclusive.
Treatments of withdrawal?
Difference?
Detoxification - get them off the drug
Maintenance- prevent relapse stay on something forever
Addiction?
3 Cs
- Chronic Disorder characterized by compulsive use
- Continue to use despite adverse consequences
- Lost control
- Denies there is a problem
Wernickes Syndrome can lead to?
Reversible non reversible?
- Karsakoff Psychosis (irreversible)
Signs and symptoms of opioid overdose or intoxication?
- Pinpoint pupils
- Cold clammy skin
- Blue/pale lips
- Confusion
- Severe drowsiness (cant wake up)
- respiratory depression
What can cause a false positive for opioids?
- Fluoroquinolones
- Dextromethorphan
- Quinine
- Rifampin
- Methadone specific assay
- Diphenhydramine
- Verapamil
Why do people abuse drugs?
- Getting high
- Pain relief, anxiety, and increase alertness
- Peers
- Easy access
- Pure and cheap
- Less “Harmful”
- Less likely risk of arrest
Carbamazepine can be used to decrease incidence of?
AW seizures
Amphetamine UDS
- Lots of false positives
- Its all cross reactive
- Amphetamine
- Methamphetamine
- MDMA
What are the naloxone rescue kits for patients and families?
- Intranasal
- Intramuscular
- Evzio (autoinjector)
Prescritption drugs that will give you a true positive for amphetamine?
False positives?
- Selegiline
- ADHD meds
- vicks nasal spray
- Pseudoephedrine, Methylphenidate, Phentermine, Bupropion, Chlorpromazine, Desipramine, Ephendrine, Ranitide, many others
Oxycodone abuse?
- Snorting
- Chewing
- Injection
Detoxification with Buprenorphine/Naloxone
- Once induction is established start dose reduction, 10-14 days usually
Who is at risk for OD?
- Using alcohol and BDZ
- High opioid dosing
- Polypharm
- Methadone
- Recent OD
- Hx of abuse
- Comorbidities
Treatment of AWS drug of choice?
What does it help?
- Benzos
- Reduces
- Severity of withdrawal
- Incidence of seizure
- Incidence of delirium
Thiamine deficiency can cause?
- Wernickes syndrome
Maintenance for Buprenorphine/ Naloxone
- Induction phase
- Stabilization
- Long term (can be forever)
Most drugs stay in your urine for about?
Ones that are longer than that?
PCP-5-7 days
THC up to 30 days maybe even longer
Adjunctive treatment?
Increased BP and P
Hallucinations
Never treat these symptoms alone without?
- Clonidine
- Haloperidol
- Always need a BZD
Methadone?
- Must be 18
- can only be given via federal approved clinic
- dependence for 1 year
- failed prior detox and pregnant women
Alcohol withdrawal treatment, Delirium tremens
Medical Emergency
- BZD Infusion
- Remember that polyethylene glycol toxicity with lorazepam
- Propofol (Anesthetic)
- Concerns that the patient is just being sedated
- Antipsychotics
- Monitor for QTC
Symptoms of withdrawal from opioids?
- Lacrimation
- Rhinorrhea
- Mydriasis
- Yawning
- Sweating
- N/V
- Diarrhea
- Insomnia
- Piloerection
- fever
- Aches
- Restlessness
- Irritability
Pharmacologic treatment for alcohol abstinence?
- Disulfram
- Naltrexone
- Acamprosate
Signs and symptoms of drug abuse?
- Tremor
- Bloodshot or glassy eyes
- Leaving randomly
- Pale
- Long sleeves
What Benzos are best for liver disease?
LOT
Lorazepam, Oxazepam and Tomazepam? Check that
Acamprosate
When can it be started?
Combination with?
AE?
- Must be used during maintenance not right after detox
- Social support is needed without that it isnt effective at all
- Combo with Naltrexone or Dilsulfram
- Diarrhea
Using medications outside of society norms?
Drug Abuse
High doses of Gabapentin has been know to have significant positive effects in patients that are?
- Heavy drinkers
You crave the drug get scared if you dont have it
Psychological dependence
Disulfram causes someone to be sick if they consume alcohol while on the medication. Why could this be an issue with this medication?
What should be monitored?
Reactions with this medication can last for how many days after discontinuation?
- Compliance limits this, if someone decides they want to drink then they just dont take the med
- Thats why its good to tell the patient to take it in the AM so they dont have the choice to say they’ll drink
- LFTs should be monitored extensive 1st pass metabolism
- 14 days after discontinuation
Naloxone?
What is it
- Opiate antagonist
- poorly absorbed sublingually
- Dissove in water and injected, the full effects of it are observed
Risk factors for addiction?
- Family history
- Male
- Peers
- Psychiatric illness
- Lack of family involvement
- Taking a super addictive drug
What are the CAGE questions how many do you have to answer yes to?
- Have you ever felt you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking
- Have you ever felt bad or guilty about your drinking?
- Have tou ever had a drink first thing in the morning to steady your nerves to get rid of hangovers? (Eye-opener)
Go over the stages of withdrawal
- Mild withdrawal
- Headache, tremors, High BP, P, agitation, insomnia,
- Hallucination
- Seizures
- DT
Maintenance?
- Methadone
- Buprenorphine/naloxone
- Naltrexone
What are some complications associated with Alcoholism?
- Gastritis
- GI Bleed
- Liver disease
- Cardiomyopathy
- Pancreatitis
- Electrolyte disturbances
- Wernickes syndrome
Alcohol Withdrawal summary
- Alcohol withdrawal is a?
- BZDs are the treatment?
- Symptom triggered methods usually result?
- Clonidine and antipsychotics are not recommended for? ANd have not been shown to?
- It is life threatening
- BZDs first line
- Lower BZD administration
- Not recommended as monotherapy since they have not shown to reduce seizures or delirium
Theres two types of ways to dose for Benzos what are they?
- Fixed dosing
- Symptoms triggered dosing with the utilization of CIWA-Ar score
What is the definition of Alcohol withdrawal?
Condition that occurs when regular alcohol consumption over an extended period of time is decreased or stopped abruptly.
What labs usually change when evaluating for AWS?
What other labs should be orders if you suspect a patient is having AWS?
- Increased ALT/AST
- Increased GGTP
- Increased MCV
- Alcohol level
- UDS
- Electrolytes
- INR- increased in late stages of liver disease
3 steps in overdose?
- Call 911 give naloxone, if no rxn after 2 minutes give second dose
- Rescue breathing or chest compression
- Follow dispatcher
- After naloxone, stay until help arrives
Tips when starting to use Buprenorphine/ Naloxone
- Stop short acting
- If withdrawal symptoms are present within 12-24 hours
- Admin 4/1 observe for 2 hours
- Symtoms relieved? thats the dose
- Max 8/2 in 24 hours
