Exam 3 Flashcards
Naloxone (Narcan)- class, indication, when to rx, half life
Potent opioid
antagonist
* Treatment of choice for
opiate overdose
* Routinely prescribe for
all patients with opioid
use disorder
* Very short half life
Length of effects 30-90 min
Methadone (Dolophine)- class, administration, federal restrictions, monitoring for adverse effects
Long-acting full opioid
receptor AGONIST at mu
receptor
* 1x/daily
* Restricted federally licensed
substance abuse treatment
programs
* Monitor for QTC prolongation
(cardiac abnormalities)
Buprenorphine (Buprenex, Sublocade)
Buprenorphine/Naloxone(Suboxone)- class, effect, indication, med forms
- Partial Opioid receptor agonist/ opioid
antagonist - Decreases cravings; *** Opioid Use disorder w/ comorbid pain= Suboxone can be used in managing pain
- Can precipitate withdrawal if used too soon after full opioid agonist – it will displace any residual opioids from the mu receptors.
- Sublingual preparation that is safer= Suboxone: Waiver needed to prescribe in outpatient settings
- Suboxone= available Buccal film, sublingual film, sublingual tab
- Buprenorphine= Available sublingual tab; subdermal implant, SQ injection
naltrexone-
class, administration including forms, what patients is this good for? Adverse effect/monitoring
Competitive opioid antagonist
* Precipitate withdrawal if used
within 7 days of heroin use
* Available orally or monthly depot
injection.
Pill works approx. 24 hours; Injection may last up to 30 days.
* **Treatment of choice for highly
motivated patients.
* Risk for LFT elevation
- Available PO (Revia)
- Available IM (Vivitrol)
***NO LIQUID
What could inappropriate use of opioids indicate?
may be an indication that the patient’s pain is uncontrolled
Opioid intoxication sx and management
Drowsiness
N/V
↓GI motility (Constipation; abdominal cramps)
Sedation
Slurred speech
Miosis(constricted pupils)
Seizures
Respiratory depression
Arthralgia/myalgia
Mgt:
Airway support
In overdose, give Naloxone (opioid antagonist)
Ventilator if required
Patients art risk of overdose should be prescribed a naloxone (Narcan) kit to keep at home for emergencies.
Opioid withdrawal- sx, management, buprenorphine or methadone for withdrawal?
Flu-like symptoms (body aches, anorexia, rhinorrhea, fever)
Diarrhea
Anxiety
Insomnia
Mgt: Buprenorphine/naloxone; Clonidine, dicyclomine (Bentyl)
Moderate symptoms= Symptomatic treatment with;
Clonidine for autonomic s/s
NSAIDs for pain, Baclofen for muscular spasms
Benzos for anxiety & agitation
Loperamide for diarrhea
Dicyclomine for abdominal cramps
Promethazine for nausea
Antinausea medications
Hypnotics for insomnia (e.g. trazodone, low dose quetiapine, diphenhydramine)
NOTE: In clinical experience, when administered for detoxification and not maintenance, buprenorphine is more effective at suppressing and controlling withdrawal symptoms as the taper nears completion compared with methadon
cocaine intoxication- sx & tx
Euphoria
Heightened self esteem
Decrease BP
Tachycardia or bradycardia
Nausea
Dilated pupils
Psychomotor agitation or depression
Chills and sweating
Dangerous/Deadly: Seizures, cardiac arrythmias, paranoia, hallucinations
**NOTE: Cocaine has vasoconstrictive effects= can cause MI, stroke
Txt: Lorazepam
cocaine withdrawal- disulfiram (Antabuse) use, meds for sx, contraindicated med
disulfiram/Antabuse use in Cocaine use disorder = increase synaptic dopamine in the brain reward circuit and act as an agonist treatment in the setting of cocaine use disorder
NOTE: Medications for cocaine-induced chest pain and myocardial infarction = Nitroglycerin, Aspirin
**No Metoprolol
(Beta blockers are contraindicated in patients with cocaine induced chest pain – further lowers coronary blood flow thereby worsening ischemia)
ETOH intoxication
- Impaired fine motor control
- Impaired judgement and coordination
- Ataxic gait and poor balance
- Lethargy, difficulty sitting upright, difficulty with
memory, - Nausea/Vomiting
- Coma = Levels 300mg/dL and over
- Respiratory depression and death possible
(***Know ETOH Intoxication vs. Withdrawal)
ETOH withdrawal (mild/mod/severe)
(***Know ETOH Intoxication vs. Withdrawal)
Mild: Insomnia, Irritability, Hand tremor
Moderate: Autonomic hyperactivity (diaphoresis, tachy, HTN), Fever
Severe: Seizures (12-48 hours post consumption); Hallucinations; Delirium Tremens (48-96 hours after last drink)
* Anxiety
* Anorexia
* Nausea/Vomiting
* Psychomotor agitation
NOTE: Use the Clinical Institute Withdrawal Assessment(CIWA) to monitor withdrawal
CIWA protocol (what does it assess? number scale mild/mod/severe?)
Areas assessed – Nausea & vomiting, tremor, paroxysmal sweats, anxiety,
agitation, tactile disturbances, auditory disturbances, visual disturbances,
headaches, orientation
CIWA scoring and what it means.
* < 10= mild;
* 10-15= moderate
* 15+= severe
First line txs ETOH use disorder (class, effect, forms, special consideration for OUD)
naltrexone (Revia; IM-Vivitrol)
- Opioid receptor antagonist
- Can be used for both ETOH and Opioid Use disorders
- Reduces desire/cravings
- First line treatment
- PO or monthly injection (Vivitrol), Implant
- Will precipitate withdrawal in patients with physical opioid dependence
*metabolized by the liver
Acamprosate (Campral)
- Likely modulates glutamate transmission
- First line treatment in maintaining abstinence after detox
- Used for relapse prevention (post detoxification)
- Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
- Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
- Contraindicated in severe renal disease.
- Decreases craving
First line treatment in maintaining abstinence from ETOH after detox (MOA, use, metabolism, contraindication, effect)
Acamprosate (Campral)
Likely modulates glutamate transmission
* First line treatment in maintaining abstinence after detox
* Used for relapse prevention (post detoxification)
* Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
* Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
* Contraindicated in severe renal disease.
* Decreases craving
Disulfiram(Antabuse)- effect, concurrent ETOH use, what to avoid, contraindications, patient population
2nd line tx ETOH use disorder
Blocks enzyme(Aldehyde dehydrogenase) in the liver
*Causes aversion reaction to ETOH(flushing, headaches, n/v, palpitation, SOB, vertigo, hypotension)
** Do not administer until the person has been alcohol free at least 12 hours
* Educate patients to refrain from using
anything that contains alcohol (vinegar,
aftershave, perfumes, mouthwash, cough medicine) while taking and up to 2 weeks after discontinuation.
* Contraindicated in severe cardiac disease, pregnancy, psychosis
* For highly motivated patients
bupropion/Wellbutrin in ETOH use disorder
Bupropion increases the risk for withdrawal seizures in ETOH patients
Tx for ETOH withdrawal
Benzos(Lorazepam,
Diazepam, Chlordiazepoxide-
Librium)= To keep patient calm and lightly sedated
MOA: Enhance the effects of GABA
Tegretol, Valproic or Gabapentin= use in mild withdrawal
Thiamine, folic acid and
multivitamin= for nutritional deficiencies
Thiamine (to prevent or
treat Wernicke’s encephalopathy= B1 deficiency) and Folate
Fluid and electrolyte balance
leading causes of death in patients with serious mental illness
The leading causes of death in patients with serious mental illness are heart disease, cancer, and cerebrovascular or respiratory disease, which can all be linked to smoking
tobacco use disorder tx options (3)
VARENICLINE(CHANTIX)
* Mimics action of Nicotine
* ***The most effective tobacco cessation
* Reduces rewarding aspects
* Prevents withdrawal symptoms
BUPROPION
(ZYBAN)
* Inhibits reuptake of dopamine and norepinephrine
* Helps reduce craving and withdrawal symptoms
NICOTINE
REPLACEMENT
THERAPY(NRT)
* Available as transdermal patch, gum, lozenge, nasal spray and inhaler
* Nicotine patch- watch for vivid dreams or sleep disruptions
WELL KNOWN METHODS TO PROVIDE BRIEF STOP
SMOKING ADVICE
5A’s:
1. Ask for the smoking status
2. Brief advice to quit
3. Assess the motivation to quit
4. Assist by providing evidence-based
treatment
5. Arrange Follow-up
ABC method/Ask and Act:
1. Ask
2. Brief advice
3. Cessation support
** Every smoker would receive an offer for treatment regardless of their motivation to treat status**
Substances r/t sexual dysfunction
Overall, substances such as alcohol, Cocaine and opioid use disorder can lead to sexual dysfunction.
What med is good for insomnia in substance use disorders?
Gabapentin has been considered as a treatment for insomnia in patients with substance use disorders - also helps with anxiety ( No sedative effects, not metabolized by the liver, does not lower seizure threshold, no blood monitoring)
For geriatric pt, if TCA needed, which is safest?
If TCA is indicated = consider Nortriptyline(fewer anticholinergic side effects)
Tx for elderly with MDD and decreased appetite
Consider mirtazapine (Remeron) = MDD w/ symptoms of insomnia and decreased appetite