Exam 2 - Opiate and Alcohol tx Flashcards
Define opiate abuse
Problematic pattern of substance use leading to clinical significant impairment
Signs and symptoms of opiate use?
Reduced mental status “nodding off”, decreased bowel sounds/constipation, miotic pupils, decreased RR, decreased BP, track marks
Clonidine, Phenergan, BZDs, Neurontin are used to do what with opiate highs?
Supplement and make even higher
Opiate withdrawl signs and symptoms?
Tachy, diaphoresis, restless/anxiety, tremor, goosebumps, yawning, myalgia, corzya, GI upset, flu-like w/o fever
COWS is clinical scale for assessing what?
Opiate withdrawl
Which drug used for acute opioid intoxication and provoked immediate withdrawl?
Narcan (Naloxone)
Narcan MOA?
Rapid Opioid antagonist
If give more than 10mg (5 doses) of Narcan over 15 minutes and no change in patient what to consider?
Not opioid intoxication but something else
What is first-line drug for managing opioate addiction?
Suboxone (Bup + Narcan)
Suboxone MOA?
Partial Mu-agonist. Bup has higher affinity for opiate Mu-receptors than any other opiate so displaces what in those receptors
If a PT on Suboxone and they take an opiate what happens?
Suboxone lessens effect of opiate
Dosing for Suboxone?
BID-TID
What special license needed for Suboxone?
X-license needed to prescribe
Suboxone and preggers?
No, use Methadone
If give Suboxone when PT is high what will happen?
PT will go into immedaite withdrawl. Wait until PT is in moderate withdrawl and then give Suboxone.
Suboxone ADRs?
Sedating, decreased RR, HA, naused, constipation, insomnia
Methadone MOA?
Full Mu-agonist
Methadone is used for what?
Chronic management of opiate abuse. To prevent ilicit use.
What does Methadone control and allow?
Controls cravings and allows a person to function
Where is Methadone dispensed?
At Methadone clinic only
What type of arrythmia does Methadone cause?
QT prolongation. Get EKG before starting Methadone.
Methadone ADRs?
OD, sedation, decreased RR, HA, nausea, constipation, diaphoresis, hypogonadism
Methadone and preggers?
OK to use
Methadone dosing?
Once a day
Acute EtOH intoxication signs and symptoms?
Bradycradic, hypotension. Slurred speech, nystagmus, disinhibition, incoordination, unsteady gait, coma, stupor.
When does Acute EtOH withdrawl start?
6-12h (or 6-24h) after last drink
Autonomic Hyperactivity is a sign of what?
Acute EtOH withdrawl
Acute EtOH withdrawl signs and symptoms
AMS, tremor, diaphoresis, hypertension, hyperthermia, N/V, anxiety/agitation, tactile disturbances, HA, seizure, auditory and visual hallucinations.
Life-threatening arrythmias, severe HTN, hyperthermia, seizure
DTs=48-96 hours in
When do the DTs start? Looks like what?
48-96 hours into EtOH withdrawl.
AMS, hallucinations, etc. Tx with BZDs.
Long-term EtOH abuse signs and symptoms?
Cirrhosis, cardiomyopathy, peripheral neuropathy (stocking glove distro), Wernicke’s Korsakoff’s, pancreatitis
Wernicke’s Korsakoff looks like? How to treat?
Confabulation, nystagmus, ataxis.
Tx=Thiamine
First-line tx for EtOH abuse?
Naltrexone/Vivitrol
PO, IM
Naltrexone/Vivitrol MOA?
Mu-opioid antagonist. Not fully understood with EtOH.
Naltrexone/Vivitrol is able to do what
Decrease total days drinking, decrease heavy drinking days, decrease cravings
Can give Naltrexone is PT is drunk? If on opiate?
Drunk=yes
Opiate=no, wait 7-10 days d/t inducing withdrawl
If PT does well on Naltrexone then what to consider next?
Vivitrol IM
Naltrexone and Vivitrol dosing?
Naltrexone=50mg/day
Vivitrol=380mg/month in butt
If PT has liver dysfunction can give Naltrexone/Vivitrol?
Use Campral instead
Campral MOA?
GABA-agonist; Glutamate antagonist
When to use Campral?
Second-line in EtOH withdrawl. Used it PT fails Naltrexone/Vivitrol.
Campral used for what?
Long-term management of EtOH abuse
Campral dosing?
Two 333mg tab BID
Campral and renal?
Adjust for renal
Campral ADRs?
Diarrhea for 1-2 weeks, GI upset, decreased libido, insomnia, anxiety, suicidal ideation, muscle weakness, dizzy
Treatment of Acute EtOH Withdrawl?
BZDs
Which med for Acute EtOH withdrawl under 60 and no liver issues
Librium
Which med for Acute EtOH withdrawl over 60 or liver issues?
Ativan
What else to manage/give during Acute EtOH withdrawl?
Give IV fluids, manage lytes
OK to give Suboxone and Naltrexone together?
NO
What is the half-life of Diazepam?
20-80h
What is the half-life of Chlordiazepoxide?
5-30h
What is the half-life of Lorazepam and Oxazepam?
10-20h
What is the half-life of Midazolam?
2-6h
Stage 1 EtOH withdrawl time range and symptoms?
6-12h after last drink. Minor withdrawl symptoms=tremor, diaphoresis, N/V, HTN, tachy, hyperthermic, tachypnea
Stage 2 EtOH withdrawl time range and symptoms?
Alcohol hallucinosis, 12-24h after last drink. Dysperceptions: auditory and visual hallucinations, tactile parasthesia
Stage 3 EtOH withdrawl time range and symptoms?
Alcohol withdrawl seizures, 24-48h after last drink. Generalized tonic-clonic seizures with little or no postictal period.
Stage 4 EtOH withdrawl time range and symptoms?
Delerium Tremens, 48-72h after last drink. Delerium, psychosis, hallucionations, malignant hypertension, seizures, and coma.
What is the main treatment goal of Alcohol Withdrawl Syndrome?
Minimize severity of symptoms in order to prevent more severe manifestations seizure, delerium, and death, and to improve patient’s quality of life.
First-line tx for Alcohol Withdrawl Syndrome?
Non-pharmacologic supportive care: quiet room, frequent assurance, nursing care, etc
How to prevent Wernicke’s Encephalopathy?
B-complex vitamins and Folates
Routine tests during Alcohol Withdrawl Syndrome?
Blood or breath EtOH concentration, CBC, renal function tests, electrolytes, glucose, liver enzymes, urinalysis and urine toxicology screening.
General supportive care during Alcohol Withdrawl Syndrome?
Correct fluid depletion, hypoglycaemia and electrolyte disturbances, and should include hydration and vitamin supplementation. In particular, thiamine supplementation and B-complex vitamins (including Folates).
Can Thiamine be given routinely during Alcohol Withdrawl Syndrome?
Yes. Absence of contraindications or significant adverse effects. Safe to give.
Can glucose be given before Thiamine in Alcohol Withdrawl Syndrome?
NO! Glucose before Thiamine makes Wernicke’s Encephalopathy worse. Give Thiamine before glucose!
What are 2 long-lasting BZD agents?
Diazepam and Chlordiazepoxide
“Gold Standard” for treating Acute Alcohol Withdrawl?
BZDs. Can actually prevent progression to next worse stage.
Criteria for ideal drug for Alcohol Withdrawl Syndrome?
Rapid onset, long duration of action for reducing withdrawal symptoms, relatively simple metabolism, not dependent on liver function. It should not interact with alcohol, should supppress the ‘drinking behaviour’ without producing cognitive and/or motor impairment and it should not have a potential for abuse
