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AC- CNS lectures > Module 3.1.2 (Management of Substance Use Disorders) > Flashcards

Module 3.1.2 (Management of Substance Use Disorders) Flashcards

1
Q

What are the THREE common steps of management?

A
  1. Assess the patient’s stage of change

> build rapport

> provide education

  1. Detoxification/Withdrawal

> Self withdrawal as outpatient or in the community or

> At a special facility or hospital

  1. Post-withdrawal management

> At home; OR

> Long term rehabilitation at a residential service

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2
Q

What are the SIX stanges of change? How to assess the patient’s stage of change

A
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3
Q

Who are pharmacists more likely to interact with in the stages of change?

A

interact with “pre-contemplators” or patients in “maintenance”

> Harm minimisation works best for pre-contemplators because it focuses on reducing harm and doesn’t enforce change for patients who do not want to change their current alcohol and drug (AOD) use. Consider:

  • Have you heard of take-home naloxone nasal sprays to reverse opioid overdoses?
  • If you decide to reduce your alcohol intake, be sure to reduce slowly because suddenly stopping can cause seizures
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4
Q

What is the goal of treatment?

A
  1. Prevent severe and potentially dangerous withdrawal symptoms e.g. seizures
  2. Manage the acute physical withdrawal symptoms to give the patient the best chance to get through to the post-withdrawal phase (abstinence)
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5
Q

What are the options for withdrawal setting? Which patients are more suitable to each one?

A
  1. Outpatient or home based withdrawal

> Suitable for patients with low risks

> Stage dispensing is highly recommended, especially for sedative medications e.g. supply of benzodiazepines to assist withdrawal

  1. Inpatient e.g. specialty facility

> For patients at risk of severe withdrawal e.g. patients at risk of alcohol or benzodiazepine withdrawal seizures

> For patients with a history of unsuccessful outpatient withdrawal

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6
Q

What are mild withdrawal alcohol symptoms?

A
  • Anxiety
  • Agitation
  • Tremor
  • Nausea
  • Tachycardia
  • Hypertension
  • Disturbed Sleeep
  • Raised temperature
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7
Q

What are severe withdrawal symptoms of alcohol?

A
  • Marked tremor
  • Vomiting
  • Extreme agitation
  • Disorientation
  • Confusion
  • Paranoia
  • Hyperventilation
  • Delirium tremens
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8
Q

When does withdrawal symptoms occur for alcohol, when does it begin, when does it settle?

A
  • Onset of withdrawal symptoms begin 6-24hrs from last consumption.
  • Withdrawal occurs when the blood alcohol level (BAL) is falling. So symptoms can begin even if the patient is intoxicated.
  • Most symptoms settle over 5 to 7 days.

> Some symptoms may last for several months e.g. insomnia and anxiety. These underlying symptoms can cause a person to lapse and relapse e.g. “I’ve been really stress and haven’t slept well for weeks! I’ll just have one drink tonight to get one good night’s sleep and it’ll be OK”.

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9
Q

When does withdrawal seizures occur with alcohol (severe)?

A

Prevalence 2-5% patients

Most occur within 6-48hrs from last consumption

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10
Q

When does delirium tremens (DTs) occur in alcohol withdrawal (severe)? What is it characterised by? When does it occur?

A

Most occur within 48-96hrs from last consumption

Characterised by:

  • Gross tremors
  • Disorientation
  • Hallucinations
  • Electrolyte imbalances.

> Untreated DTs can have a mortality rate of up to 15%. Effective treatment reduces the mortality rate to around 1%

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11
Q

What are risk factors for severe withdrawal for alcohol?

A
  • Previous history of severe withdrawal e.g. seizures, DTs.
  • Electrolyte imbalance e.g. hypokalaemia & hypomagnesemia
  • Compromised liver function e.g. cirrhosis
  • Higher levels of alcohol consumption e.g. >20 standard drinks per day
  • Advanced age
  • Concurrent medical conditions e.g. diabetes, epilepsy
  • Concurrent withdrawal from medications e.g. benzodiazepines
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12
Q

What two medications are used for alcohol withdrawal management?

A

Benzodiazepines (BZD) and Thiamine (vitamin B1)

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13
Q

Why are BZDs use for alcohol withdrawal manaagement? Which ones are used?

A

Primary medication of choice. BZD augment the inadequate inhibitory effects of GABA during alcohol withdrawal.

  • Diazepam is preferred because it is well absorbed orally, has a rapid onset and a prolong duration of action
  • Lorazepam is preferred in patients with compromised liver function
  • Cease after 5-7 days
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14
Q

Why is thiamine (vitamin B1) used for alcohol withdrawal management?

A

Thiamine (vitamin B1) is recommended for every alcohol dependent patient to treat Wernicke’s encephalopathy and prevent Korsakoff’s syndrome.

> Wernickes encephalopathy: brain injury caused by a lack of the nutrient thiamine

> Korsakoff syndrome: severe deficiency of thiamine leads to chronic memory disorder

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15
Q

What is used to monitor for alcohol withdrawal management?

A

Alcohol Withdrawal Scale (AWS) / Clinical Institute Withdrawal Assessment (CIWA)

> 10 questions on withdrawal symptoms

> higher the score, more intense the withdrawal symptoms

> diazepam indicated for scores of > or equal to 9

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16
Q

For alcohol withdrawal management, explain what drugs are used for symptomatic relief of:

A) N and V

B) Muscle aches and pain

A

A)

  • Metoclopramide
  • Ondansetron

B)

  • Paracetamol
  • Ibuprofen
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17
Q

What three medications are used to assist in maintaining abstinence in alcohol management?

A

Naltrexone, Acamprosate, Disulfiram

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18
Q

For acamprosate

A) MOA and effect

B) CI

C) Side effects and monitoring

A

A)

  • A synthetic GABA analogue that may act by restoring the glutamate and GABA-ergic systems to normal activity. This decreases the positive reinforcement of drinking alcohol and withdrawal cravings. It can:

> Reduce cravings

> Increase alcohol-free days

> Reduce alcohol intake during relapse

B)

  • Hepatic impairment
  • Pregnancy
  • If serum creatinine >120 micromol/L

C)

  • Rash, diarrhoea, changes in libido
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19
Q

For disulfiram

A) effect/MOA

B) CI

C) Side effects and monitoring

PRIVATE medication, not PBS subsidised unlike the other two

A

A)

  • Inhibits alcohol dehydrogenase and prevents the breakdown of the toxic alcohol metabolite acetaldehyde
  • Accumulation of acetaldehyde can cause flushing, sweating, nausea, vomiting, palpitations, headache, dyspnoea, chest pain, hypotension, seizures, arrhythmias.

B)

  • Severe renal or hepatic impairment
  • Pregnancy
  • Cardiovascular diseases, diabetes, stroke or psychosis

C)

  • Nausea, headache, fatigue, drowsiness, taste disturbances
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20
Q

For naltrexone

A) effect/MOA

B) CI

C) Side effects and monitoring

A

A)

  • Inhibits the effects of endogenous opioids, which are released during alcohol consumption, at the mµ receptor sites. This reduces the reinforcing effects of alcohol. It can:

> Reduce cravings

> Increase alcohol-free days

> Reduce alcohol intake during relapse.

B)

  • Acute hepatitis or liver failure
  • Pregnancy

C)

  • Nausea, headaches, dizziness, fatigue, anxiety.
  • Monitoring: Conduct liver function test before initiation, then monthly for the first 3 months then, if normal, every 3 months thereafter
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21
Q

What may be used for abstinence for fourth line?

A

Baclofen –> low risk, stable mental health and low risk of seizures

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22
Q

What is the link between tobacco and alcohol?

A
  • Up to 90% of people with severe alcohol use disorders smoke cigarettes
  • Encourage smoking cessation at the same time as alcohol withdrawal treatment
  • People often have a habit of drinking and smoking at the same time, the sight of an alcohol bottle or the smell of cigarettes can trigger the response to drink and smoke
23
Q

What is the link between tobacco and substance used disorders (SUD)?

A
  • In Australia most cannabis users mix cannabis with tobacco (‘spin’) commonly 50:50 and therefore are tobacco dependent (again, each substance promotes relapse to the other).
  • Opioid use disorder is associated with the highest smoking rates, lowest quit rates and no sustained benefits from NRT or varenicline.
  • Smoking cessation reduces cravings for psychostimulants.

> Patients with SUDs are motivated to quit.

> Patients with SUDs are more likely to achieve abstinence if they also receive treatment for smoking simultaneously

> Smoking rates in Australia are highest in SUD (higher than in mental illness)

> Pharmacist are extremely important to help select and counsel on NRT.

24
Q

What is used to make lean?

A

Rikodeine + phenergan + lemonade

25
Q

What are some practical considerations for opioid withdrawal?

A

Is it safe to consider opioid cessation at this point in time for the patient?

  • Withdrawal will remove tolerance
  • Relapse is common and will increase the risk of accidental overdose
  • Is it safer to be on an opioid substitution treatment (OST)?
26
Q

What are factors that support complete opioid cessation?

A
  • Social stability e.g. employment, accommodation, relationships
  • Sound post-withdrawal plan and support
  • Well developed insight
  • No illicit opioid use for 6-12 months if they are on OST
27
Q

What are early, peak, late opioid withdrawal symptoms

A

opioid withdrawal symptoms = flu and gastro at the same time

early

  • Runny eyes and nose, sneezing, yawning
  • Sweating, hot and cold flushes
  • Loss of appetite
  • Goosebumps

peak

  • Strong cravings -
  • Stomach cramps and diarrhoea -
  • Nausea and vomiting -
  • Body aches -
  • Restlessness, agitation, irritability and insomnia -
  • Lethargy and poor concentration -
  • Hot and cold flushes with increased sweating

late

  • Physical symptoms begin to subside
  • Psychological symptoms such as lethargy, irritability, cravings and insomnia may persist but in lower severity
28
Q

What is the clinical opioid withdrawal scale (COWS)?

A

Objective assessment e.g. clinician rates the patient’s symptoms

11 questions on the opioid withdrawal symptoms

29
Q

Intensity and duration of withdrawal symptoms are dependent on the opioid used. Compare heroin (short acting), intermediate acting (methadone) and long acting (burpenorphine.

A
30
Q

How many half lives from last use of substance for withdrawal symptoms to begin?

A

Generally, it takes 2 half lives from last use of the substance for withdrawal symptoms to begin. Drugs that are more potent and have shorter half lives are associated with more intense withdrawal symptoms, but with a shorter duration

31
Q

Why may clonidine be used for opioid withdrawal? What is MOA? What does it require montoring for?

A

t can reduce the severity of withdrawal symptoms of nausea, vomiting, diarrhoea, abdominal cramps, agitation and sweating.

  • a2-adrenoreceptor and imidazoline agonist indicated for managing opioid withdrawal symptoms.
  • It does not reduce opioid cravings.
  • Requires monitoring for hypotension, bradycardia and sedation. Avoid if the BP <90/50mmHg or HR <50 bpm.
32
Q

Why is buprenorphine used for opioid withdrawal? What are the advantages over clonidine? What happens if administered buprenorphine too early?

A

why is it used

  • Short course of buprenorphine can reduce the intensity of withdrawal from heroin, methadone, and prescription opioids
  • Minimum risk of dependence or rebound discomfort with short courses of ≤ 5 days

advantages

  • Withdrawal symptoms are milder in intensity -
  • Reduce the use of other symptomatic relief medications e.g. diazepam
  • Fewer adverse effects e.g hypotension and sedation -
  • Higher treatment retention and completion rates

administering buprenorphine too early may cause precipitated withdrawal

33
Q

what is used for symptomatic relief for withdrawal symptoms of opioids for the following

A) N and V

B) muscle aches and pain

C) agitation/anxiety

D) insomnia

E) abdominal cramps

F) diarrhoea

A

A)

Metoclopramide and ondansetron

B)

paracetamol and ibuprofen

C)

diazepam

D)

temazapam

E)

hyoscine butylbromide

F)

loperamide

34
Q

Why is opioid withdrawal during pregnancy a high-risk option? What is associated with better outcomes?

A

Relapse will expose the mother and child to illicit substance use. Withdrawal during the 1st and 3rd trimester is also associated with a higher risk of miscarriage

  • Opioid substitution treatment (OST) is associated with better outcomes for the mother and child compared to continued opioid misuse or withdrawal.

> can withdraw from OST in the 2nd trisemester if mother remains motivated on achieving abstinence and has good support

35
Q

What is used for relapse prevention in opoids? Why may it put the patient at greater risk of overdose?

A

Naltrexone

  • Reversible competitive opioid antagonist.
  • Indicated for “adjunctive” treatment in opioid relapse prevention but not PBS approved.
  • Only consider in patients who are highly motivated and have good support.
  • Naltrexone treatment will reduce the patient’s opioid tolerance and place them at greater risk of overdose if they become non-compliant and resume illicit opioid use
36
Q

Take home naloxone (THN) to prevent fatal opioid overdose, aim is to reduce deaths from opioid overdoses. Explain how naloxone works.

A
  • Competitive opioid antagonist able to reverse the effects of opioid intoxication
  • Following IM or intranasal, time to effect of 1-2 minutes with duration of effect of 30-90 minutes –> shorter DOA than naltrexone
  • Relatively few adverse effects, no abuse potential and very effective in reversing opioid overdose
37
Q

Patients that purposely misuse BZD and who are at risk of immediate harm generally have the following features…?

> Some patients take BZDs long term, just as prescribed by their regular GP, without evidence of misuse. These patients may be “therapeutically dependent” and will find it very difficult to cease or withdrawal. Withdrawal should proceed slowly and needs to be a collaborative process between patient, doctor and pharmacist

A
  • Have a history of substance use disorders e.g. alcohol, opioids
  • Often on multiple types of BZD and prescribed by multiple doctors
  • Regularly attempt to obtain early supplies
38
Q

What does withdrawal symptoms of BZD depend on?

A
  • Duration and peak of withdrawal is dependent on the half-life
  • BZDs with shorter half-lives tend to have more intense withdrawal symptoms over a shorter time-frame
39
Q

What are some common BZD withdrawal symptoms

A

Anxiety § Agitation and irritability § Restlessness § Insomnia § Tremors, muscle aches and twitches § Depression § Poor concentration and memory

40
Q

What are some less common withdrawal symptoms?

A

Seizures § Delirium § Hallucinations § Depersonalisation § Nausea § Anorexia § Hypersensitivity to sound, light, touch and taste

41
Q

Benzodiazepine withdrawal can be safely managed in an outpatient setting. What strategies can help reduce the risk of misuse?

A
  • Have an agreed treatment contract with the patient
  • Prescription should be for a short duration with limited quantities
  • Arrange for staged supply at one pharmacy
  • Arrange for a non-using significant other to supervise administration e.g. family member
  • Have regular appointments to review and support the patient.
42
Q

Benzodiazepine withdrawal management, inpatient is recommended for patients who?

A
  • Have a history of withdrawal seizures
  • Have failed past attempts at outpatient withdrawal
  • Are chaotic and require a brief period of stabilisation away from their drug use
43
Q

What are the FIVE withdrawal steps of BZDs?

A
  1. The total reported BZD dose is converted to a diazepam equivalent dose. This reduces the risk of administering multiple BZDs. The longer half-life of diazepam creates a smoother taper and less intense withdrawal.
  2. Start on this equivalent dose or immediately reduce by 20% to 50% (be mindful that some patients may overestimate their BZD use)
  3. Divide the dose and give in 3 to 4 divided doses throughout the day.
  4. Assess the patient’s response to this initial dose. Monitor for signs and symptoms of toxicity or withdrawal.
  5. If the patient tolerates the dose on the first 1 to 2 days, start decreasing the dose by 2.5mg-5mg every 1 to 5 days. Patients generally tolerate a faster reduction at higher doses of diazepam e.g. above 40 mg per day. Consider reducing by 2.5mg-5mg per week for doses below 40mg.

> The dose should be reduced quicker and by larger amounts if the patient appears drowsy or sedated

> The dose should be reduced slower and by lower amounts if withdrawal symptoms are severe

44
Q

Different forms of methamphetamine?

A
  • Crystals - “ice”. High purity (80-90%) and high potency
  • Paste - “base”. Low to medium purity (10-20%) and medium potency
  • Powder – “speed”. Low purity (10%) and lower potency
45
Q

CNS, neurological and behavioural effects of acute methamphetamine use?

A

Overstimulation, restlessness, increased energy, reduced fatigue and insomnia -

Heightened alertness, headache, mydriasis, dizziness and tremors -

Overconfidence, violent, unpredictable or irrational behaviour -

Euphoria -

Bruxism (teeth grinding) -

Seizures and coma -

Anorexia (appetite suppression) -

Confusion and psychosis (hallucinations, delusions and paranoia)

46
Q

Cardiovascular effects of acute methamphetamine use?

A

Hypertension

Palpitations

Tachycardia, arrhythmia

Angina, acute coronary syndrome, aortic dissection

47
Q

Other effects of acute methamphetamine use?

A
  • Tachypnoea (increased respiration), respiratory failure
  • Pyrexia (increased temperature)
  • Flushing or pallor
  • Diaphoresis (sweating)
48
Q

Methamphetamine withdrawal symptoms summary

A
49
Q

Most cases of methamphetamine withdrawal can be managed in an outpatient setting. However the cravings to use again can be very strong. Inpatient withdrawal is indicated for patients who fail outpatient withdrawal, or if there are complicating factors e.g. unstable mental health.

Treatment is focused on relieving withdrawal symptoms and providing supportive care …… and?

A
  • Medications to manage withdrawal symptoms
  • Non-medication counselling to help manage withdrawal symptoms
  • Strategies for relapse prevention
  • Organise appointments with other support services for after withdrawal

> Most symptoms will gradually subside over the following weeks but fluctuations in mood, sleeping disturbances and cravings may persist for weeks to months.

50
Q

What medications to use for symptomatic relief of meth

> unlikely to come across unless in ED

A
51
Q

for meth

A) what to use for relapse prevention

B) pharmacotherapy

A

A)

  • Modafinil, bupropion, naltrexone, methylphenidate, and dexamfetamine.

B)

  • Lisdexamfetamine for the treatment of methamphetamine addiction (LiMA)

The N-ICE Trial: A trial of N-Acetyl-Cysteine (NAC) for methamphetamine dependence –> Restore brain glutamate homeostasis thereby reducing craving and relapse

52
Q

What is done for post-withdrawal management?

A
  • Risk of relapse is highest during the first 12 months following withdrawal. The risk slowly reduces the longer abstinence is maintained
  • Patients with strong motivations more abstinence and those with a sound postwithdrawal plan are more likely to maintain abstinence.
  • Remain non-judgemental and supportive if a patient has a lapse or relapse e.g. “You haven’t failed. Lapses can happen. Lets try again when you are ready”
  • Patients who can develop a supportive social circle away from drug using acquaintances are more likely to succeed in abstinence.
53
Q

Practical tips for pharmacist helping patients with SUDs?

A

If you can, build rapport first. It’s hard to help someone that doesn’t come back. §

Ask questions non-judgmentally and find out about the person before making recommendations. Be genuine. People with SUDs tend to be sensitive to perceive judgement, whether this perception is correct or not. §

Don’t take interactions personally. The patient may be under the influence of drugs, not ready to listen, or most likely be emotionally fragile and having a bad day. §

Maintain your boundaries. Be clear on what you can and can’t do and stick to it. §

For example: A regular patient turns up early for their diazepam supply. They’ve run out of repeats and it’s 8pm. The GP is closed. They say they need it to prevent seizures. What do you do? –> go to ED

AC- CNS lectures (28 decks)

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