NSG 552 EXAM 3 Flashcards by Mr. Bobbits

Cluster of disorders in which cognitive, behavioral and physiological symptoms indicate that a person continues using a substance despite substance-related problems (American Psychiatric Association, 2013)

“Sub-“

Substance Use Disorders

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Drug use that is inconsistent with social use patterns.

“abu-“

Abuse

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Reversible syndrome caused by a specific substance affecting memory, judgement, behavior or social or occupational functioning

“intox-“

Intoxication

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Substance specific symptoms that occur after stopping or reducing use (opposite of the drug’s intoxication symptoms).

“withd-“

Withdrawal

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Needing more of the substance to get the desired effect.

“Tol-“

Tolerance

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Reinforcement occurs in the:

“Ven- teg-“ and “Nuc- accu-“

Ventral tegmental area (VTA) and the Nucleus accumbens (Reward center)

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Positive rewards of reinforcement= mediated by ____ pathways.

“D-“

DA (dopamine)

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____________ release within the reward center is enhanced by the release of natural morphine-like neurotransmitters (Neuropeptides- enkaphalins, beta endorphins).

“Dop-“

DA (dopamine)

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Repeated drug use —> ________ system becomes increasingly sensitized.

“Dop-“

DA (dopamine)

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Classes of Substance Use Disorders:

Caffeine, nicotine, amphetamines, cocaine, ecstasy

“stim-“

stimulants

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Classes of Substance Use Disorders:

Benzodiazepines, Alcohol

“depr-“

depressants

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Classes of Substance Use Disorders:

Opioids

“narc-“

narcotics

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Classes of Substance Use Disorders:

Lysergic acid diethylamide (LSD) Marijuana

“hall-“

hallucinogens

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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

This is?

“alc- intox-“

alcohol intoxication

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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

What is this?

“alc- withd-“

alcohol withdrawal

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________ withdrawal: Insomnia, Irritability, Hand tremor

“mil-“

mild

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________ withdrawal: Autonomic hyperactivity (diaphoresis, tachy, HTN), Fever

“mod-“

moderate

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________ withdrawal: Seizures (12-48 hours post consumption); Hallucinations; Delirium Tremens (48-96 hours after last drink)

“sev-“

severe

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Alcohol Withdrawal delirium: Initial treatment is a ___________.

Careful with the use of antipsychotics because they lower the seizure threshold.

“benz-“

benzodiazepine

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____________________: Initial treatment is a benzodiazepine.

Careful with the use of antipsychotics because they lower the seizure threshold.

“alc- wit- del-“

Alcohol Withdrawal delirium

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Alcohol Withdrawal delirium: Initial treatment is a benzodiazepine.

Careful with the use of antipsychotics because the lower the _______ threshold.

“seiz-“

seizure

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Alcohol Withdrawal delirium: Initial treatment is a benzodiazepine.

Careful with the use of _____________ because the lower the seizure threshold.

“anti-“

antipsychotics

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Opioid receptor antagonist
Reduces desire/cravings
First line treatment – Good for heavy drinkers
PO or monthly injection (Vivitrol) - great for patients with non-compliance issues.
Will precipitate withdrawal in patients with physical opioid dependence.
D/C 48-72 hours prior to receiving opiate analgesia.

Which med is this?

“nalt-“

naltrexone (Revia, Vivitrol [IM])

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Functions as “artificial alcohol” by reducing glutamate activity.

Reduces neuronal hyperactivity during early alcohol recovery – helps sustain abstinence.
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 – good for individuals who are abstinent or recently relapsed.

Which med is this?

“acamp-“

acamprosate (Campral)

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Functions as “artificial alcohol” by reducing glutamate activity.

Which med is this?

“acamp-“

acamprosate (Campral)

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Reduces neuronal hyperactivity during early alcohol recovery – helps sustain abstinence.

Which med is this?

“acamp-“

acamprosate (Campral)

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Likely modulates glutamate transmission

Which med is this?

“acamp-“

acamprosate (Campral)

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First line treatment in maintaining abstinence after detox

Which med is this?

“acamp-“

acamprosate (Campral)

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Used for relapse prevention (post detoxification)

Which med is this?

“acamp-“

acamprosate (Campral)

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Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)

Which med is this?

“acamp-“

acamprosate (Campral)

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Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol

Which med is this?

“acamp-“

acamprosate (Campral)

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Contraindicated in severe renal disease.

Which med is this?

“acamp-“

acamprosate (Campral)

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Decreases craving – good for individuals who are abstinent or recently relapsed.

Which med is this?

“acamp-“

acamprosate (Campral)

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Opioid receptor antagonist

Which med is this?

“nalt-“

naltrexone (Revia, Vivitrol [IM])

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Reduces desire/cravings

Which med is this?

“nalt-“

naltrexone (Revia, Vivitrol [IM])

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First line treatment – Good for heavy drinkers

Which med is this?

“nalt-“

naltrexone (Revia, Vivitrol [IM])

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PO or monthly injection (Vivitrol)- great for patients with non-compliance issues.

Which med is this?

“nal-“

naltrexone (Revia, Vivitrol [IM])

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Will precipitate withdrawal in patients with physical opioid dependence.

Which med is this?

“nalt-“

naltrexone (Revia, Vivitrol [IM])

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D/C 48-72 hours prior to receiving opiate analgesia.

Which med is this?

“nalt-“

naltrexone (Revia, Vivitrol [IM])

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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

Which med is this?

“disul-“

disulfiram (Antabuse)- 2nd line

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Blocks enzyme(Aldehyde dehydrogenase) in the liver

Which med is this?

“disul-“

disulfiram (Antabuse)- 2nd line

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Causes aversion reaction to ETOH(flushing, headaches, n/v, palpitation, SOB, vertigo, hypotension)

Which med is this?

“disul-“

disulfiram (Antabuse)- 2nd line

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Do not administer until the person has been alcohol free at least 12 hours

Which med is this?

“disul-“

disulfiram (Antabuse)- 2nd line

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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.

Which med is this?

“disul-“

disulfiram (Antabuse)- 2nd line

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Contraindicated in severe cardiac disease, pregnancy, psychosis

Which med is this?

“disul-“

disulfiram (Antabuse)- 2nd line

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For highly motivated patients

Which med is this?

“disul-“

disulfiram (Antabuse)- 2nd line

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Potentiates GABA and inhibits Glutamate
Reduces cravings
Remember DOPE-a-max (impaired cognition, nausea, weight loss, metabolic acidosis.

Which med is this?

“topi-“

topiramate (Topamax) - 2nd line

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Potentiates GABA and inhibits Glutamate

Which med is this?

“topi-“

topiramate (Topamax) - 2nd line

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Reduces cravings

Which med is this?

“topi-“

topiramate (Topamax) - 2nd line

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Remember DOPE-a-max (impaired cognition, nausea, weight loss, metabolic acidosis.

Which med is this?

“topi-“

topiramate (Topamax) - 2nd line

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Treatment of withdrawal: (Three benzos to keep patient calm and lightly sedated.

“L, D, and C”

lorazepam (Ativan)
diazepam (Valium)
chlordiazepoxide (Librium)

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MOA: Enhance the effects of GABA

Which drug class?

“B-“

Benzodiazepines

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Use these three meds in mild withdrawal:

“Gab-, Valp-, and Car-“

gabapentin (Neurontin)
valproic acid (Depakene)
carbamazepine (Tegretol)

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Use these three meds in ____ withdrawal:

gabapentin (Neurontin)
valproic acid (Depakene)
carbamazepine (Tegretol)

“mi-“

mild

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Three supplements used for nutritional deficiencies in treatment of withdrawal.

“t” “f” “m”

Thiamine, folic acid and multivitamin

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These two supplements used to prevent or treat Wernicke’s encephalopathy (B1 deficiency)

“pare- thi-“ and “fol-“

Parenteral thiamine and folate

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Another important thing for tx of withdrawal:

“flu” and “ele” balance

Fluid and electrolyte balance

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CIWA Score <10 =

“mi-“

mild

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CIWA score 10-15 =

“mod-“

moderate

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CIWA score 15 =

“sev-“

severe

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Banana Bag ingredients (i.e. thiamine, multivitamin, folic acid).

What are we trying to prevent?

“Wern-“

Wernicke’s encephalopathy

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__________ blocks reuptake of dopamine, epinephrine and NE = Stimulant effect

“coc-“

Cocaine

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Euphoria
Heightened self esteem
Decreased 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

What is this?

“coc- intox-“

cocaine intoxication

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Post intoxication depression “Crash”

Fatigue
Malaise
Hypersomnolence
Depression
Anhedonia
Hunger
Constricted pupils
Vivid dreams

What is this?

“coc- with-“

cocaine withdrawal

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NO FDA approved med for treatment of which condition?

“coc- with-“

cocaine withdrawal

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Off-label med treatment for cocaine withdrawal =

“Nalt-,” “modaf-,” and “Topi-“

Naltrexone, modafinil, Topamax

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Supportive care for which condition ?

(control HTN, arrhythmias)

“coc- with-“

cocaine withdrawal

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Used for mild-moderate agitation in cocaine withdrawal =

“benz-“

Benzodiazepines

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Used for severe agitation or psychosis in cocaine withdrawal:

“antip-“

antipsychotics

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___________ 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

“disul-“

disulfiram (Antabuse)

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NOTE: Medications for cocaine-induced chest pain and myocardial infarction =

“nitr-“ and “aspi-“

Nitroglycerin, Aspirin

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NOTE: Medications for cocaine-induced chest pain and myocardial infarction =

Nitroglycerin, Aspirin

Don’t use which med?

“meto-“

metoprolol (Lopressor)

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Often used in dance clubs and raves

“Amp-“

Amphetamines

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Have both stimulant and hallucinogenic properties

“Amp-“

Amphetamines

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Intoxication is similar to cocaine

“Amp-“

Amphetamines

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Can cause ongoing psychosis

“Amp-“

Amphetamines

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Withdrawal can cause prolonged depression

“Amp-“

Amphetamines

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Txt: Rehydrate, correct electrolyte and treat hyperthermia

“Amp-“

Amphetamines

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Intoxication effects of which drug?

Rage
Erythema
Dilated pupils
Delusions
Amnesia
Nystagmus
Excitation
Skin dryness

“Phen-“

(Phencyclidine) PCP

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Treatment for which drug?

Treatment: Supportive care (rehydration, electrolyte balance etc.)

Benzos for agitation, anxiety, muscle spasms
Haldol for severe agitation and psychosis

“Phen-“

(Phencyclidine) PCP

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Regarding which illicit substance?

No withdrawal
Recurrence of intoxication due to release of the drug from body lipid stores.

(Phencyclidine) PCP

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Nystagmus (Red-bolded) side effect of which drug?

“Phen-“

(Phencyclidine) PCP

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The below are part of which drug class?

Benzos, barbiturates, Zolpidem, zaleplon, GHB(date rape drug),

“sed- hyp-“

sedative hypnotics

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Intoxication side effects of which drug class?

Drowsiness
Confusion
Hypotension
Slurred speech
Incoordination
Ataxia
Mood lability
Impaired judgment
Respiratory depression or death in OD

“sed- hyp-“

sedative hypnotics

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Regarding withdrawal of which drug class?

Abrupt abstinence after chronic use can be life-threatening.

“sed- hyp-“

sedative hypnotics

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Intoxication treatment for which drug class?

Maintain airway, breathing and circulation
Supportive care (improve respiratory status, control hypotension)
Activated charcoal and gastric lavage to prevent further GI absorption= in Overdoses
Benzos= Flumazenil in OD (Benzo antagonist)

“sed- hyp-“

sedative hypnotics

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For benzodiazepine OD (a sedative hypnotic) which medication would you use (a benzo antagonist)?

“flu-“

flumazenil

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Regarding withdrawal treatment of which drug class?

Benzodiazepines (stabilize patient and taper gradually)
Carbamazepine or valproic acid (taper not as beneficial)

“sed- hyp-“

sedative hypnotics

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Benefits of use regarding which substance?

decreasing N/V
increasing appetite in AIDS patients
decreasing chronic pain from cancer
lowering intraocular pressure in glaucoma

“mari-“

marijuana

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Euphoria, anxiety, impaired motor coordination, mild tachycardia, Conjunctival injection “red eyes”, dry mouth, Munchies= increased appetite

Cannabis induced Psychotic disorder: paranoia, hallucinations and delusions.

These are side effects of intoxication of which substance?

“mari-“

marijuana

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Irritability, anxiety, restlessness, aggression, strange dreams, depression, headaches, insomnia, low appetite

Withdrawal effects of which substance?

“mari-“

marijuana

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Supportive care
Based on symptoms

Treatment options for which substance?

“mari-“

marijuana

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Restlessness
Insomnia
Anxiety
Increased GI motility

Effects from which substance?

“nico-“

nicotine

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Intense craving
Dysphoria
Anxiety
Poor concentration
Increased appetite
Weight gain
Irritability
Restlessness
Insomnia

Withdrawal of which substance?

“nico-“

nicotine

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Varenicline(Chantix)

Mimics action of Nicotine
The most effective tobacco cessation
Reduces rewarding aspects
Prevents withdrawal symptoms

Treatment for which substance?

“nico-“

nicotine

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Bupropion (Zyban)

Inhibits reuptake of dopamine and norepinephrine
Helps reduce craving and withdrawal symptoms

Treatment for which substance?

“nico-“

nicotine

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Nicotine Replacement therapy (NRT)

Available as transdermal patch, gum, lozenge, nasal spray and inhaler
Nicotine patch- watch for vivid dreams or sleep disruptions

Treatment for which substance?

“nico-“

nicotine

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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.

T/F

True

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This drug class stimulates mu, kappa and delta opiate receptors

Effects on the dopaminergic system which mediates their addictive and rewarding properties

“opio-“

Opioids

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Drowsiness
N/V
↓GI motility (Constipation; abdominal cramps)
Sedation
Slurred speech
Miosis(constricted pupils)
Seizures
Respiratory depression
Arthralgia/myalgia

Intoxication effects of which drug class?

“Opio-“

Opioids

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Flu-like symptoms (body aches, anorexia, rhinorrhea, fever)
Diarrhea
Anxiety
Insomnia

Withdrawal effects of which drug class?

“Opio-“

Opioids

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opium
heroin
morphine
oxycodone
methadone
hydrocodone
codeine

Examples of which drug class?

“Opio-“

Opioids

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Airway support
In overdose, give Naloxone (opioid antagonist)
Ventilator if required
Patients at risk of overdose should be prescribed a naloxone (Narcan) kit to keep at home for emergencies.

Treatment for intoxication of which drug class?

“Opio-“

Opioids

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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 methadone

Treatment for the withdrawal of which drug class?

“Opio-“

Opioids

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This is regarding which drug class?

“Opio-“

Opioids

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Naloxone (Narcan)

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

Treatment for which drug class?

“Opio-“

Opioids

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Methadone (Dolophine)

Long-acting full opioid receptor AGONIST at mu receptor
1x/daily
Restricted federally licensed substance abuse treatment programs
Monitor for QTC prolongation (cardiac abnormalities)

Treatment for which drug class?

“Opio-“

Opioids

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Buprenorphine (Buprenex, Sublocade)
Buprenorphine/Naloxone(Suboxone)

Partial Opioid receptor agonist/ opioid antagonist
Decreases cravings
Can precipitate withdrawal if used too soon after full opioid agonist
Sublingual preparation that is safer
Suboxone: 2023- Consolidated Appropriations Act, 2023 removed special waiver needed to prescribe for the treatment of Opioid Use Disorder (OUD).
Must have a DEA Schedule III authority to prescribe.

Treatment for which drug class?

“Opio-“

Opioids

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Naltrexone

Competitive opioid antagonist
Pill works approx. 24 hours; Injection may last up to 30 days.
Precipitate withdrawal if used within 7 days of heroin use
Available orally or monthly depot injection.
Treatment of choice for highly motivated patients.
Risk for LFT elevation

Treatment for which drug class?

“Opio-“

Opioids

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Decreased mortality with overdose.

Which drug class?

“opi- ago-“

Opioid Agonists (Buprenorphine/Methadone)

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Need to successfully complete opioid withdrawal prior to treatment.
Precipitates withdrawal in patients actively using opioids

Which drug class?

“opi- ant-“

Opioid Antagonists (Naltrexone)

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Buprenorphine

Preferred as initial treatment
Lower risk of death in overdose – lower potential of causing respiratory depression.
Providers can prescribe this in outpatient settings – no waiver required.
Fewer drug-drug interactions.

Buprenorphine vs Methadone

Regarding which drug class?

“opio-“

Opioids

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Methadone

For individuals with high tolerance
Appropriate for patients with higher level of physical dependance or prior misuse/diversion of buprenorphine
Requires daily visits to a licensed opioid treatment program (OTP)

Buprenorphine vs Methadone

Regarding which drug class?

“opio-“

Opioids

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NOTE: If this medication is used too soon after a patient’s last opioid use, ________________ will displace any residual opioids from the μ receptors and can precipitate withdrawal symptoms

“bupr-“

buprenorphine

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Opioid Use disorder w/ comorbid pain = this med can be used in managing pain

“sub-“

Suboxone

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Inappropriate use of opioids may be an indication that the patient’s pain is uncontrolled.

True or False?

True

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Includes psilocybin (mushrooms), mescaline (peyote cactus) and lysergic acid diethylamide (LSD)

“hallu-“

Hallucinogenics

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Illusions
Hallucinations
Body image distortions
Labile affect
Dilated pupils
Tachycardia
HTN
Hyperthermia
Tremors
Incoordination
Sweating
Palpitations

Intoxication effects of which kind of substance?

“hallu-“

Hallucinogens

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Do not cause physical dependence or withdrawal

Regarding which kind of substance?

“hallu-“

Hallucinogens

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May use Benzos and antipsychotic medications for agitation

Regarding treatment for which kind of substance?

“hallu-“

Hallucinogens

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generally act as CNS depressants
Most common in preadolescents or adolescents
E.g. solvents, glue, paint thinners, fuels, isobutyl nitrates (“huffing” “laughing gas” “rush”)

Regarding which substance?

“inha-“

inhalant

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Perceptual disturbances
Paranoia
Lethargy
Dizziness
Nausea/vomiting
Headache
Nystagmus
Tremor
Muscle weakness
Ataxia
Slurred speech
Euphoria
Clouding of consciousness
Stupor or coma

Intoxication effects of which kind of substance?

“inha-“

inhalants

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Does not usually occur
Irritability
Sleep disturbance
Anxiety
Depression
Nausea/vomiting
Craving

Withdrawal effects of which kind of substance?

“inha-“

inhalants

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Airway monitoring; Chelation depending on solvent

Treatment on the intoxication of which substance?

“inha-“

inhalants

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Loss of ability to control the use of inhalants

Regarding which substance?

“inha-“

inhalants

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Compulsivity to use inhalants

Regarding which substance?

“inha-“

inhalants

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Negative emotional state when not sniffing/breathing inhalants

Regarding which substance?

“inha-“

inhalants

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Common among teenagers

Regarding which substance?

“inha-“

inhalants

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E.g., volatile solvents, aerosols, gases, nitrites

Regarding which substance?

“inha-“

inhalants

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Methods: Sniffing, spraying into nostrils or mouth, bagging, huffing- breathing in from rag soaked with the chemical; inhalation from balloons

Regarding which substance?

“inha-“

inhalants

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Clinical presentation regarding which substance?

Ataxia
Smell of chemicals on body or clothing
Sores and scabs around nose and mouth (Glue Sniffer’s rash)
Slurred speech
Drowsiness
Headaches

“inha-“

inhalants

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Emergency effects regarding which substance?

Agitation
Fever
Seizures
Hallucinations
Confusion
Loss of consciousness
Coma
Fatal accidental injury

“inha-“

inhalants

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Treatment/management for which substance?

Treat presenting symptoms
Benzodiazepines for managing withdrawal and emergency symptoms (e.g., Valium, Lorazepam.

“inha-“

inhalants

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This med comes in po, injection and implant (NO LIQUID)

“nalt-“

Naltrexone

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Most-used psychoactive substance in the United States
Coffee, tea or energy drinks

“caff-“

caffeine

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Anxiety
Insomnia
Muscle twitching
Rambling speech
Flushed face
GI disturbance
Restlessness
Excitement
Tachycardia
More than 1g= tinnitus, severe agitation, cardiac arrhythmias
More than 10g = Death can occur secondary to seizures and respiratory failure

Intoxication effect of which substance?

“caff-“

caffeine

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Occurs if cessation is abrupt

Headache
Fatigue
Irritability
Nausea
Vomiting
Drowsiness
Muscle pain
Depression

Withdrawal effects of which substance?

“caff-“

caffeine

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Supportive and symptomatic

Treatment for which substance?

“caff-“

caffeine

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When assessing and treating older adults, clinicians not only need to take the above factors into account but also need to consider the potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants.
The Alcohol Use Disorders Identification Test (AUDIT) and the CAGE often are used to screen for at-risk substance use or misuse among older adults
Alcohol problems are common among older adults.
The use of pharmaceutical drugs is prevalent in older adulthood, and the risk of misusing prescription and over-the-counter medications, which include substances such as sedatives/hypnotics, narcotic and nonnarcotic analgesics, diet aids, and decongestants, also increases with age.
Incidentally, benzodiazepines also tend to be one of the most inappropriately prescribed psychotherapeutic medications among older adults

*Geriatric Considerations (part 1)

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Clinicians should be cautious when prescribing or recommending a treatment, take both risks and benefits into account when determining a treatment plan, and clearly communicate guidelines for appropriate use to patients.
Clinicians also should carefully consider discontinuing medications that do not prove effective
Illicit drug use among older adults is rare.
Thus, rates of illicit substance use and abuse among older adults will likely continue to rise in the next several decades because of the aging of the baby boom cohort.
When assessing and treating older adults, clinicians not only need to take the above factors into account but also need to consider the potential interaction between alcohol and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants.

*Geriatric Considerations (part 2)

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Red bolded part of geriatric considerations:

-The potential interaction between this substance and both prescribed and over-the-counter medications, especially psychoactive medications such as benzodiazepines, barbiturates, and antidepressants.

“alco-“

alcohol

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Alcohol, Cocaine and opioid use disorder can lead to sexual dysfunction.

True or false?

True

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Withdrawal seizures are commonly associated with which substances?

“alco-, benz-“

Alcohol, benzodiazepines

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Medical Emergency
Reversible
40% mortality
Commonly experienced by patients in the ICU and post-op
Develops over hours to days
Subtypes: Hyperactive (agitated, restless, hyperalert); Hypoactive(lethargic, slowed, apathetic); Mixed(cycles between hyperactive and hypoactive
Causes: DELIRIUM(Drugs, Electrolyte imbalance, Low oxygen sat, Infection, Reduced sensory input, Intracranial(strokes), Urinary retention, Myocardial)

What condition is this?

“deli-“

delirium

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Txt: Symptom treatment

1:1 sitter

Agitation and Psychotic symptoms:

Haldol (PO, IM, IV); Atypical antipsychotics

Treatment of which condition?

“deli-“

delirium

Group of disorders characterized by gradual development of cognitive deficits
Irreversible

Types
*Alzheimer’s disease (AD)= most common
*Vascular disease = 2nd most common
*Lewy body disease (LBD)
*Frontotemporal degeneration (FTD)
HIV infection
Huntington disease (HD)

Which condition is this?

“deme-“

dementia

Gradual progressive decline
Most common type of dementia
Affects memory, learning and language
Aphasia (difficulty with speech)
Apraxia (inability to perform previously learned tasks
Agnosia (inability to recognize an object

Etiology: Accumulation of beta-amyloid plaques and intraneuronal tau protein tangles

Txt: Cholinesterase inhibitors
NMDA receptor antagonists

Which type of dementia?

“alz-“

Alzheimer’s disease

2nd most common type of dementia
Cognitive decline secondary to large vessel strokes
Risk factors: HTN, DM, Smoking, obesity, HLD, A-fib, Age

Which type of dementia?

“vasc-“

vascular dementia

Characterized by waxing and waning cognition
Visual hallucinations (well formed images of animals and small people)
Develop EPS (Parkinsonism) @ least 1 year after cognitive decline

Etiology: Lewy bodies and Lewy neurites in brain (primarily basal ganglia)

Txt: Cholinesterase inhibitors
- Seroquel and Clozaril (low doses/short term)
- Levodopa/Carbidopa
- Melatonin and/or Clonazepam (REM sleep disorder)

NOTE: There is potential for severe sensitivity reactions, including exacerbation of parkinsonism, confusion, or autonomic dysfunction, which limits the usefulness of antipsychotic medications in these patients = Sensitive to antipsychotics

Which type of dementia?

“lew-“

Lewy Body Disease (LBD)

40% familial
Atrophy of the frontal and temporal lobes

Personality/Behavioral
- Disinhibition (verbal, physical sexual)

Language
- Difficulty with speech and comprehension

Kluver-Bucy Syndrome: hypersexual, hyperorality

Txt:
- Symptom focus
- SSRI to help with inhibition

Which type of dementia?

“fron-“

Frontotemporal Degeneration (FTD)

Cholinesterase Inhibitor
Slows clinical deterioration by 6-12 months
Once daily dosing
For mild-moderate NCD
Not effective in severe, end-stage disease
Should STOP if side effects of nausea/vomiting develop

S/E: diarrhea, weight loss, abnormal dreams, insomnia, dizziness

Which med for dementia is this?

“Donep-“

Donepezil (Aricept)

Twice daily dosing
GI side effects
For mild –moderate NCD

Which dementia med is this?

“gala-“

Galantimine (Razadyne)

Cholinesterase Inhibitor
Twice daily dosing
For mild-moderate AD & Parkinson’s disease dementia
Transdermal patch available – daily form with fewer side effects
For Mild to moderate NCD
Highest GI side effects

Which dementia med is this?

“Riva-“

Rivastigmine (Exelon)

Mood symptoms = SSRIs

Aggression/Agitation/Psychosis

Consider atypical antipsychotics (Zyprexa, Seroquel, Risperdal, Haldol)

Note: Reserve Benzos for short term and acute episodes

This is treatment for which condition?

“deme-“

Dementia

NMDA receptor antagonist
Moderate – severe disease
Fewer side effects as compared to the Cholinesterase inhibitors
Promotes synaptic plasticity
May be used in conjunction with cholinesterase inhibitors

e.g. Namzric (Mamantine/Donepezil)

**May cause hallucinations

Which dementia med is this?

“mema-“

Memantine (Namenda)

Pharmacologic Category: Anti-Amyloid Monoclonal Antibody; Immune Globulin; Monoclonal Antibody

Lequembi targets harmful amyloid proteins; reducing existing amyloid brain plaque.

Alzheimer disease: IV: Dosing based on actual body weight: 10 mg/kg once every 2 weeks.

LEQEMBI can cause serious side effects including:

Amyloid Related Imaging Abnormalities or “ARIA”. ARIA is a side effect that does not usually cause any symptoms, but serious symptoms can occur.ARIA is most commonly seen as temporary swelling in areas of the brain that usually resolves over time. Some people may also have small spots of bleeding in or on the surface of the brain, and infrequently, larger areas of bleeding in the brain can occur. Most people with this type of swelling in the brain do not get symptoms, however some people may have symptoms, such as:

–headache
–confusion
–dizziness
–vision changes
–nausea
–difficulty walking
–seizures

LEQEMBI reference

This dementia med as compared to Aricept and Namenda

= Highest adverse GI effects

“riva-“

Rivastigmine

Patch available with fewer GI side effects.

Which med is this?

“riva-“

Rivastigmine (Exelon)

Use of this drug class in dementia particularly Lewy Body Dementia.

“anti-“

antipsychotics

Decreased protein levels = more free meds in the body= risk for toxicity

Regarding what?

“nor- ag-“

normal aging

Regarding aging, if a TCA is indicated:

consider this med (fewer anticholinergic side effects)

“nort-“

Nortriptyline

Regarding aging:

Consider this med = MDD w/ symptoms of insomnia and decreased appetite

“Reme-“

Remeron

Regarding aging:

This med = can be used in low doses as an adjunct to antidepressants for patients with severe depression and/ or psychomotor retardation.

“methyl-“

Methylphenidate

Regarding aging:

Consider which dangerous thing?

“poly-“

Polypharmacy

More likely to cause side effects when used (i.e. memory impairment, ataxia, paradoxical excitement and rebound insomnia) = Trazodone is a safer options

Regarding which drug class?

“sed- hyp-“

sedative hypnotics

The issue of ___________ is of particular concern in older people who, compared with younger individuals, tend to have more disease conditions for which therapies are prescribed.

“poly-“

polypharmacy

This increases the potential for drug-drug interactions and for prescription of potentially inappropriate medications

“poly-“

Polypharmacy

________ medications are associated with multiple adverse effects to which older individuals are particularly susceptible.

These include memory impairment, confusion, hallucinations, dry mouth, blurred vision, constipation, nausea, urinary retention, impaired sweating, and tachycardia

“antic-“

Anticholinergic

Developed by an expert consensus panel in 1991
Most widely cited criteria used to assess inappropriate drug prescribing
The criteria are a list of medications considered potentially inappropriate for use in older patients, mostly due to high risk for adverse events.

https://www.elderconsult.com/wp-content/uploads/PrintableBeersPocketCard.pdf

“Beer-“

Beers Criteria

Effect of ____ use in the elderly =

Anticholinergic (dry mouth, confusion, blurred vision, urinary retention, constipation etc.)

“Coge-“

benztropine (Cogentin)

feeling, thoughts and /or behaviors that are acceptable to self, consistent with one’s fundamental personality

“ego s-“

Ego-syntonic

feelings, thought and/or behaviors that are distressing, unacceptable or inconsistent with one’s self concept.

“ego d-“

Ego dystonic

Familial association with psychotic disorders

Patient seem eccentric, peculiar or withdrawn

Schizoid
Schizotypal
Paranoid

Which cluster?

Cluster A

Familial association with mood disorders

Patients seem emotional, dramatic or inconsistent

Antisocial
Borderline
Histrionic
Narcissistic

Which cluster?

Cluster B

Familial association with anxiety disorders.

Patients seem anxious or fearful

Avoidant
Dependent
Obsessive-compulsive

Which cluster?

Cluster C

Personality disorders are generally very difficult to treat especially since few patients will acknowledge they need help
These disorders tend to be chronic and lifelong
Pharmacologic treatments have limited usefulness except when treating comorbid mental conditions (e.g. MDD)
Psychotherapy is usually most helpful

Cluster A

General distrust for others
Suspicion (without evidence)
Reluctance to confide in others
Suspicions regarding fidelity of spouse or partner

Txt:

Psychotherapy is 1st line
Short course of antipsychotic for transient psychosis

“para-“

Paranoid

Cluster A

Prefer to be alone (voluntary social withdrawal)
Few close friends or confidants
Emotionally cold, detached or flattened affect.

Txt:

May benefit from day programs or drop in centers
Consider antidepressants if comorbid depression is present

“schizoi-“

schizoid

Cluster A

Odd beliefs or magical thinking
Odd /eccentric

Txt:
- Psychotherapy is 1st choice
- Short course of low dose Atypical antipsychotic may help with the cognitive-perceptual disturbances

“schizot-“

schizotypal

Cluster B

Failure to conform to social norms
Deceitful, manipulative for personal gain
Reckless, irritable
Lack remorse

NOTE: Begins as conduct disorder in childhood

Txt:
- Psychotherapy is ineffective
- Treat symptoms of anxiety, depression or aggression but with caution d/t high comorbidity with substance use disorders

“antis-“

Antisocial

Cluster B

Fear of abandonment
Aggression
Impulsive
Repeated SI attempts/gestures/self-mutilation
“Splitting”

Txt: Gold standard = Dialectical behavior therapy (DBT)

Pharmacotherapy as adjunct to psychotherapy.
Mood stabilizers and low dose antipsychotic meds have been found to be effective for mood swings and lability.

“bord-“

Borderline Personality Disorder (BPD)

Cluster B

Attention seeking
Dramatic, flamboyant and extroverted.
Unable to form long-lasting, meaningful relations.

Txt: Psychotherapy is 1st line
- Pharmacotherapy to treat associated depressive or anxious symptoms

“histr-“

Histrionic

Cluster B

Grandiosity
Requires excessive admiration
Sense of entitlement
Lacks empathy
Arrogant or haughty

Txt: Psychotherapy is 1st line
- Use psychotropics if comorbid psychiatric disorders are diagnosed

“narc-“

Narcissistic

What is the gold standard txt for borderline personality disorder?

Dialectical behavior therapy (DBT)

Cluster C

Intense fear of rejection
Fear of embarrassment and criticism
Isolates from relationships

Txt:
- Psychotherapy
- SSRI= if comorbid social anxiety or depression

“avoi-

Avoidant

Cluster C

Poor self confidence
Cannot make everyday decisions without reassurance from others
Feels helpless when alone

Txt:
- Psychotherapy
- Treat comorbid anxiety or depression

“Depe-“

Dependent

Cluster C

Preoccupation with details, rules, lists, organization
Excessive devotion to work
Will not delegate tasks
Rigid and stubborn

Txt:
- Psychotherapy (CBT)
- Treat comorbid anxiety or depression

“Obses-“

Obsessive compulsive Personality Disorder (OCPD)

First-line treatment for personality disorders is psychotherapy.
Symptom-focused, medication treatment of personality disorders is generally considered to be an adjunct to psychotherapy.
Avoid prescribing medications that can be fatal in overdose, such as tricyclic antidepressants.
Avoid prescribing medications that can induce physiological dependence and tolerance, including benzodiazepines.
Avoid changing medication each time there is a crisis or change in mood symptoms, which may occur frequently and suddenly, and also remit suddenly in some people with personality disorders.
Symptom expression in patients with personality disorders often waxes and wanes in relationship to life circumstances.

General Guidelines

Cognitive and perceptual disturbances
Impulsivity or behavioral dyscontrol
Affective dysregulation

Antidepressants and mood stabilizers are dosed as they would be for major depressive disorder and bipolar disorder (e.g. Lithium, Lamictal)

Antipsychotics are in general used at a lower dosing range compared with doses used in the treatment of schizophrenia (e.g. Abilify, Risperdal, Seroquel)

“Tar- sym- dom-“

Targeted Symptom Domains

Note: Causes of sexual dysfunctions maybe physiological (medication side effects/medical conditions), psychological (depression, substance use) or both; Abnormal levels of gonadal hormones (estrogen, testosterone, progesterone)

Dopamine enhances libido
Serotonin inhibits sexual function

General Information

enhances libido

“dop-“

dopamine

inhibits sexual function

“ser-“

serotonin

Most of the antidepressants except Bupropion (Wellbutrin) & Mirtazepine (Remeron) cause sexual problems

E.g. low libido, anorgasmia, erectile dysfunction

Antipsychotics = ↑ prolactin (low libido, gynecomastia, galactorrhea, erectile dysfunction etc.)

Addressing medication induced sexual dysfunction:

Medication reduction
Switching to another medication
Prescribe another medication (e.g. PDE-5 inhibitors)

__________(1) - take 30 min to 4hours before sexual activity

____________(2) - take 30-60 min before sexual activity

Note: Avoid concomitant use w/ nitrates (e.g. nitroglycerine, isosorbide dinitrate, amyl nitrate “poppers”)

Caution with patients taking alpha-adrenergic blockers

“sild-“

“tada-“

(1) Sildenafil (Viagra)

(2) Tadalafil (Cialis)

The combination of sildenafil and meds such as nitrates can cause an unsafe drop in blood pressure.

True or False?

True

Absent or deficiency of sexual thoughts, desire or fantasies for more than 6 months

Txt

Testosterone as replacement therapy (in men and postmenopausal women)
Low dose vaginal estrogen replacement –improves vaginal dryness and atrophy in postmenopausal women
Medications that increase DA and NE (e.g. Flibanserin and bupropion) may also be used

Which sexual disorder?

“mal-“

Male Hypoactive sexual desire disorder

Difficulty obtaining or maintaining an erection
Most common sexual dysfunction in men

Txt
Sildenafil (Viagra)
Phosphodieterase-5 inhibitor (PDE-5)
Enhances blood flow to the penis
S/E: headaches, flushing, dizziness, hypotension

May cause prolonged erection and priapism

Which disorder is this?

“erec-“

Erectile disorder /Erectile dysfunction/Impotence

Recurrent pattern of ejaculation during sex within 1 minute and before individual wishes it

Txt
Prolong time from SSRI and TCAs stimulation to orgasm
(e.g. Clomipramine, Fluoxetine, Paroxetine)

“prem-“

Premature Ejaculation

Absence or reduced sexual interest, thoughts, fantasies, initiation of sex, sexual arousal

“fema-“

Female sexual interest/arousal disorder

Premature ejaculation= using this med (15mg and 30mg) taken 2- hours before intercourse is effective and safe treatment.

“clom-“

clomipramine

Description:
- Enduring pattern of anger or irritable mood, argumentative, defiant or vindictive behavior
- Common in males

Management:
- Target symptoms = mood and aggression
- Treat comorbid conditions (such as ADHD)
- Behavior modification

“Opp-“

Oppositional defiant disorder (ODD)

Description:
- Violates the rights of other humans and animals
- Inflicts cruelty and harm through physical and sexual violence
- May lack remorse

Management:
- Behavioral modification, family and community
- Meds used to target comorbid symptoms and aggression (SSRIs, guanfacine, propranolol, mood stabilizers, antipsychotics)

“Cond-“

Conduct Disorder

Description:

Characterized by impairments in social communication/interaction and restrictive, repetitive behaviors/interests
4:1 ration (male/female)
Recognized ages - 12-24 months

Management:
- Early intervention, behavioral therapy, psychoeducation
- Alpha-2 agonists (clonidine, guanfacine) and low dose atypical antipsychotics (Risperidone, Abilify)= to help reduce disruptive behaviors, aggression and irritability
- Melatonin for sleep,
- Remeron for sleep, anxiety

“Auti-“

Autism Spectrum disorder(ASD)

Sudden, rapid, repetitive, stereotyped movements or vocalizations
Anxiety, excitement and fatigue are aggravating factor for tics
Tourette’s disorder: most severe characterized by multiple motor tics (face, head, eye blinking, throat clearing) an at least one vocal tic lasting for at least 1 year
Vocal tics( Copralalia/Echolalia)

Management:
- Behavioral interventions
- Consider meds if tics become severely impairing.
- 1st choice: Guanfacine (alpha-2 agonist) Clonidine (more sedating)
- Severe cases, consider atypical (e.g. risperidone)

“Tic-“

Tic disorder
(Tourette’s)

First choice med for Tic disorder
(Tourette’s)?

“guan-“

Guanfacine (alpha-2 agonist)

Antipsychotic medications for Autism

INDICATION: Autism associated irritability, aggression, temper tantrums, self-injurious behaviors, mood lability

AGE RANGE: Children 5+ and Adolescents less than 18
(weight based)

“Risp-“

Risperidone (Risperdal)

Antipsychotic medications for Autism

INDICATION: Autism associated irritability, aggression, temper tantrums, self-injurious behaviors, mood lability

AGE RANGE: Children and Adolescents 6-17 years old

“arip-“

Aripiprazole (Abilify)

Regarding atypical antipsychotics for autism, what is one thing you should monitor for?

“seda-“

sedation

Recurrent urination into clothes or bed wetting

Treatment: Psychoeducation, behavioral program

1st line: Desmopressin (DDAVP) an antidiuretic
2nd line: Imipramine (TCA) at low doses

NOTE: Symptoms are not due to substance (e.g. laxatives) or another medical condition (e.g. anal fissure, spina bifida

“enu-“

enuresis

Recurrent defecation into inappropriate places (e.g. clothes, floor)

Treatment: Psychoeducation, bowel retraining

NOTE: Symptoms are not due to substance (e.g. laxatives) or another medical condition (e.g. anal fissure, spina bifida

“enco-“

encopresis

Impaired cognitive and adaptive/social functioning.

Deficits in intellectual functioning (i.e. reasoning, problem solving, planning, abstract thinking, judgement and learning)
Deficits in adaptive functioning i.e. communication, social participation and independent living.
Severity is mild, moderate, severe and profound

Causes: Genetic (Down syndrome); Prenatal (rubella, herpes simplex etc.) Perinatal (Anoxia, prematurity, birth trauma) and Postnatal (malnutrition, toxin exposure, trauma)

Management: Behavioral Therapy

“Inte-“

Intellectual Disability Disorder (IDD)

Difficulty acquiring and using language due to expressive and/or receptive impairment (e.g. reduced vocab). Increased risk in families of affected individuals

Treatment: Speech and language therapy, family counseling

“lang-“

Language disorder

(Phonological Disorder)- difficulty producing articulate, intelligible speech

Treatment: Speech and language therapy, family counseling

“spee-“

Speech Sound Disorder

(stuttering)- Dysfluency and speech motor production issues.

Treatment: Speech and language therapy, family counseling

“chil-“

Childhood–onset fluency disorder

Challenges with the social use of verbal and non-verbal communication

Treatment: Speech and language therapy, family counseling

“soci-“

Social (pragmatic) communication disorder

Characterized by inattention, hyperactivity and impulsivity inconsistent with the patient’s developmental stage.
Males > females

Etiology:
- Abnormalities of fronto-subcortical pathways (i.e. frontal cortex and basal ganglia)
- Dopamine dysfunction
- NE dysfunction

“atte-“

ADHD

Notably – response to a stimulant does not prove a dx of this disorder

The first-line pharmacological tx are stimulants which help to increase DA in PFC

MOA: Increase DA in the prefrontal cortex, nucleus accumbens and reward circuitry

Treatment: Multimodal(i.e., Medications + educational and behavioral interventions)

1st line: Stimulants (methylphenidate compounds, dextroamphetamine, mixed amphetamine salts)= Ritalin, Concerta, Adderall (Scchedule II)

Side effects: GI upset, anorexia, weight loss, BP changes, ↑ HR, Growth suppression(rare),sleep disturbance, jitteriness, headaches, dizziness, mood lability -irritability, psychosis (rare), social withdrawal

“AD-“

ADHD

1st line: Stimulants for ADHD?

“Rit-,” “Conc,” “Adde-,”

(methylphenidate compounds, dextroamphetamine, mixed amphetamine salts)

Ritalin, Concerta, Adderall

response to a stimulant does not prove a dx of ______.

“AD-“

ADHD

2nd line: Alpha-2 agonists (Clonidine, guanfacine)

Can be used instead or as an adjunctive therapy to stimulants
Used in children who respond poorly to other meds, experience side effects or have coexisting conditions such as tics.

Treatment for which disorder?

“AD-“

ADHD

2nd line: Alpha-2 agonists for ADHD

Can be used instead or as an adjunctive therapy to stimulants
Used in children who respond poorly to other meds, experience side effects or have coexisting conditions such as tics.

“clon-,” “guan-“

(Clonidine, guanfacine)

NE reuptake inhibitor (consider when a hx or family hx of illicit substance use is present) for use of ADHD.

Which medication?

“Atom-“

Atomoxetine (Strattera)

First line = Stimulants (Methylphenidate; Dexmethylphenidate )

**Monitor Height, weight, BP, CBC w/ diff; Pulse quarterly (Height and weight d/t risk of growth restriction)

In healthy individuals, it is not necessary to obtain an EKG prior to initiating a stimulant
Prescription Monitoring Program should be checked

MOA: Boosts dopamine, NE and 5HT

Methylphenidate (Ritalin, Concerta)

Schedule II
Watch for Leukopenia or anemia
Common side effects(loss of appetite, headache, stomachaches, nausea, weight loss, insomnia) -Taking AM dose after eating breakfast can also help manage s/e of nausea or decreased appetite

NOTE: Long-acting forms help with convenience and reduce the rebound side effects. Long acting avoids dosing in school

DO NOT USE WITH PREEXISTING CARDIAC CONDITIONS & SYMPTOMS

FDA approved for children 6+

E.g. Short acting Ritalin (3-4 hours duration)

E.g. Long acting Ritalin LA (8-10 hours); Concerta (10-12 hours)

DO NOT USE WITH PREEXISTING CARDIAC CONDITIONS & SYMPTOMS

“stim-“

stimulants

Long-acting forms help with convenience and reduce the rebound side effects. Long acting avoids dosing in school

“stim-“

stimulants

FDA approved for children 6+

“stim-“

stimulants

Short acting Ritalin hours duration?

3-4 hours

Long acting Ritalin hours duration?

8-10 hours

Long acting Concerta hours duration?

10-12 hours

**Monitor Height, weight, BP, CBC w/ diff; Pulse quarterly (Height and weight d/t risk of growth restriction)

“stim-“

stimulants

First line stimulants?

“methyl-,” “Dexme-“

Methylphenidate; Dexmethylphenidate

Schedule II d/t high potential for abuse/diversion
May help reduce adverse effects in those who had good response to methylphenidate, but dosing limited because of adverse effects.
Short Acting (Dexedrine, Adderall; Focalin)= 4-6 hours duration
Long Acting (Adderall XR, Vyvanse)= 8-12 hours
FDA approved for children 3+

Side effect: Loss of appetite, headaches, ↑BP; stomachaches, nausea, weight loss, insomnia, anticholinergic, tics/repetitive movements, psychosis

“Dextro-“

Dextromethylphenidate (Dexedrine, Adderall)

FDA approved stimulant for children 3+ years.

“Dextro-“

Dextromethylphenidate (Dexedrine, Adderall)

Many formulations, all focused on increasing dopamine, norepi
Immediate release, Extended releases (of varying durations of action)
Daytrana transdermal patch
Immediate release provides pulsatile release pattern that leads to higher addiction liability than ER formulations
ER formulation sometimes used twice daily depending on duration of action of individual
Choice often driven by insurance formularies: general rule of thumb is to pick either a methylphenidate or an amphetamine formulation and then switch if not responding after titration to reasonable dose

Regarding formulations on which med class?

“stim-“

stimulants

Symptomatic cardiovascular disease
- Moderate to severe hypertension
- Hyperthyroidism
- Known hypersensitivity or idiosyncrasy to sympathomimetic amines
- Motor tics or Tourette syndrome
- Glaucoma
- Agitated states
- Anxiety
- History of drug abuse
- Concurrent use or use within 14 days of the administration of monoamine oxidase inhibitors

Contraindications to which drug class?

“stim-“

stimulants

Note: A PMHNP might consider using a nonstimulant medication like _______ for ADHD if:

Stimulants are not working well to control ADHD symptoms
Stimulants cause too many side effects
The child or teen has problems with substance abuse
The child or teen has a medical condition for which stimulants cannot be used - e.g. tic disorder

“guan-“

guanfacine

Labs to obtain before starting ADHD meds?

CBC w/ diff

Black box warning for SI thinking in children/adolescents
A Selective Norepinephrine Reuptake Inhibitor
FDA approved in children 6+
Not classified as a controlled substance (less abuse potential)
Alternative to stimulants for children and adolescents who have a substance abuse problem, household member with substance abuse problem, tics or severe side effects from stimulants.
Less effective
Rare liver toxicity

Which non-stimulant ADHD med is this?

“atom-“

Atomoxetine (Strattera)

Black box warning for SI thinking in children/adolescents

“atom-“

Atomoxetine (Strattera)

Alternative to stimulants for children and adolescents who have a substance abuse problem, household member with substance abuse problem, tics or severe side effects from stimulants.

“atom-“

Atomoxetine (Strattera)

Lowers seizure threshold

“bupro-“

Bupropion (Wellbutrin)

This drug class = can be used alone or as adjunctive txt.

Clonidine = helps with over aroused, easily frustrated, highly active, aggressive impulsivity and hyperactivity ; Monitor BP

Guanfacine (Tenex/Intuniv- Long acting): Rarely but can cause low BP and cardiac arrhythmias. FDA approved for children 6-17years

Can take up to 2 weeks to see clinical response
Often used if stimulant not effective enough or not tolerated
Tends to best target sx of children/adolescents including hyperarousal, hyperactivity, aggression, low frustration tolerance
No tics reported
Must be tapered to avoid rebound hypertension

“alph-“

Alpha 2 adrenergic agonist (BP meds)

helps with over aroused, easily frustrated, highly active, aggressive impulsivity and hyperactivity ; Monitor BP

“clon-“

clonidine

Rarely but can cause low BP and cardiac arrhythmias. FDA approved for children 6-17years

“guan-“

guanfacine (Tenex/Intuniv- Long acting)

Relatively new (approval 2021)
Approved for children ages 10+
Non-stimulant
Norepinephrine reuptake inhibitor
Common s/e: nausea, decreased appetite, insomnia, GI upset, diarrhea/constipation, tremor, dizziness, orthostatic hypotension
Rare but serious suicidal thoughts/behaviors, seizure

“Qelb-“

Qelbree (viloxazine)

CII med
Needs secure electronic prescribing (often two step electronic verification)
Can sometimes write for 90 day supply if it says “for ADHD” but this varies by insurance
Many settings use stimulant agreements to set expectations for management with stimulant
Not everyone is a good candidate for safe use of stimulants
Non-pharm treatments are sometimes helpful alternatives or adjuncts
Dosing can be variable by person for many stimulants

RX considerations for which drug class?

“stim-“

stimulants

This drug class (Clonidine, guanfacine) are used if first line treatment cannot be used (due to intolerable side effects or ineffectiveness) or as adjunctive therapy for stimulants.

“alph-“

Alpha-2 agonists

We discussed the management of alcohol dependence and withdrawal this week with an emphasis on pharmacological interventions. Identification of intoxication and withdrawal is essential to timely and effective treatment for any substance related symptoms. For alcohol, intoxication would likely be impairment in balance, slurred or impaired speech patterns, slowed reaction times, confusion, and sometimes nausea and vomiting. Supportive care is really the only thing indicated at this point and can include fluids, antiemetics, and supervision. Acute withdrawal would be managed with benzodiazepines (lorazepam is often chosen since it can also be given orally or parenterally). Seizure prevention is important and can be achieved with benzodiazepines. Traditional anticonvulsants have been found to be less efficacious than benzodiazepines. It is important not to administer or prescribe anything that can lower the seizure threshold as some antidepressants can do. Thiamine plays an important role in detox for preventing Wernicke’s encephalopathy. For treatment of dependence options include acamprosate, disulfiram, and naltrexone. Naltrexone is great although should not be used in the presence of elevated LFTs. Acamprosate would be better tolerated for someone who has some degree of liver impairment. Disulfiram works by causing nausea and vomiting with the ingestion of alcohol and is key in assisting a behavioral approach to alcohol abstinence (also works to increase dopamine in the reward pathways in the brain and can be useful in treating cocaine dependence).

To recap opiate use disorder- acute intoxication with an opiate (heroin, oxy, fentanyl…) is marked by slowed (sometimes significantly) respirations, low levels of consciousness, slowed heart rate, low blood pressure, constricted pupils, and possibly a lower body temp. Acute intoxication is best treated quickly so naloxone is the best choice for pharmacological treatment. Withdrawal often manifests with watery eyes, flu like symptoms, anxiety, GI distress, and diarrhea. Pharmacological treatment can be initiated with buprenorphine/naloxone (suboxone) but may also include clonidine.

Additional substance use disorders to be aware of are cocaine and other stimulants, and nicotine. S&S of acute intoxication of cocaine would include agitation, aggressiveness, muscle twitching, high blood pressure, elevated heart rate, increased temp, hallucinations, and pupil dilation. Treatment for this acute intoxication is best achieved with benzodiazepines, preferably parenteral. Chest pain can also accompany cocaine use disorders. Benzos can help, but nitroglycerine is also used to relieve this. Beta blockers should be avoided due to the possibility of exacerbating vasoconstriction. Important to note, there is no FDA approved pharmacologic treatment for cocaine and stimulant use disorders.

Nicotine use disorder is most appropriately treated initially with nicotine replacement therapy. Smoking cigarettes is directly linked with heart disease, cancer and cardiovascular disease. This poses a special risk to those with mental illness, especially those who are on other metabolically offensive agents and/or those who practice unhealthy dietary and activity patterns.

Week 9 recap notes.

Acute withdrawal would be managed with __________________ (lorazepam is often chosen since it can also be given orally or parenterally). Seizure prevention is important and can be achieved with the same drug class.

“benz-“

benzodiazepines

It is important not to administer or prescribe anything that can lower the seizure threshold as some ______________ can do.

“anti-“

antidepressants

_________ plays an important role in detox for preventing Wernicke’s encephalopathy.

“thia-“

Thiamine

For treatment of dependence options include acamprosate, disulfiram, and ____________. _____________ is great although should not be used in the presence of elevated LFTs.

“nal-“

Naltrexone

For treatment of dependence options include _____________, disulfiram, and naltrexone. _________ would be better tolerated for someone who has some degree of liver impairment.

“acam-“

Acamprosate

For treatment of dependence options include acamprosate, _________, and naltrexone. ___________ works by causing nausea and vomiting with the ingestion of alcohol and is key in assisting a behavioral approach to alcohol abstinence (also works to increase dopamine in the reward pathways in the brain and can be useful in treating cocaine dependence).

“disu-“

Disulfiram

Acute opiate intoxication is best treated quickly so ____________ is the best choice for pharmacological treatment.

“nalo-“

naloxone

Withdrawal often manifests with watery eyes, flu like symptoms, anxiety, GI distress, and diarrhea. Pharmacological treatment can be initiated with _______________(1) but may also include ___________(2).

“bup-“ “clon-“

(1) buprenorphine/naloxone (suboxone)

(2) clonidine

S&S of acute intoxication of _______ would include agitation, aggressiveness, muscle twitching, high blood pressure, elevated heart rate, increased temp, hallucinations, and pupil dilation.

“coca-“

cocaine

Treatment for acute intoxication of cocaine is best achieved with _________, preferably parenteral.

“benz-“

benzodiazepines

Chest pain can also accompany ________ use disorders. Benzos can help, but nitroglycerine is also used to relieve this.

“coca-“

cocaine

Regarding acute intoxication of cocaine, _____________ should be avoided due to the possibility of exacerbating vasoconstriction.

“beta-“

Beta blockers

Important to note, there is no FDA approved pharmacologic treatment for ________ and ________ use disorders.

“coca-,” “stim-“

cocaine, stimulant

_________ use disorder is most appropriately treated initially with nicotine replacement therapy. Smoking cigarettes is directly linked with heart disease, cancer and cardiovascular disease. This poses a special risk to those with mental illness, especially those who are on other metabolically offensive agents and/or those who practice unhealthy dietary and activity patterns.

“Nico-“

Nicotine

Pre-existing cardiac issues can pose increased risk for adverse cardiac events when using a ___________.

“stim-“

stimulant

For behaviors related to ____________, behavioral treatment is the first line.

“inte-“

IDD (intellectual disability disorder)

Abrupt onset of sexual dysfunction that correlates with the initiation of an _____ is likely due to the _____. You should still take the time to assess other etiologies, but firstly reducing the dose if clinically plausible is a good strategy for management.

“SS-“

SSRI

In males, _______________ should be ruled out if there is a desire disorder.

“hypo-“

hypogonadism

If premature ejaculation is problematic, __________ can be used on demand, but other SSRI can also be used on a daily basis (or on demand, although the literature supports _____________ the most in the on demand method. In practice, several are used such as paroxetine and sertraline).

“clom-“

clomipramine

Remember that for older males, there are likely other causes of erectile dysfunction. In the presence of medical conditions such as CVD and diabetes, medications are not likely the culprit. If they have CVD and are on ____________, you must proceed with caution as this can cause blood pressure to drop.

“nitr-“

nitrates

ED is not a primary psychiatric disorder, so this condition can be referred to PCP. Especially if there are comorbid medical conditions. Medications like __________ are only indicated for once daily dosing and have not been studied to be used more than this.

“sild-“

sildenafil

____________ disorders are notoriously difficult to treat and pharmacologic options have limited benefit. We generally treat the comorbid psychiatric illness and treat symptomatically. When deciding on pharmacological treatment, one must take the entire picture into context and make medication decisions based on doing the least harm while balancing the potential benefits. It is essential to know the relative safety profiles of medications to be able to effectively choose.

“pers-“

Personality

Reinforcement occurs in the __________ and the __________.

“ven-teg- ar-“ and “nucl- accu-“

Ventral tegmental area (VTA)

Nucleus accumbens (Reward center)

___________ can be used for both ETOH and opioid use disorders

“nalt-“

Naltrexone

Benzodiazepines in borderline personality disorder (any personality disorder). Should it be used?

No, due to high risk for substance abuse and lethality in overdose

Treatment recommendations caution against pharmacological treatment of the primary traits of ASPD? True or False?

True

A 52-year-old man is brought into the emergency department with complaints of “feeling unwell.” He is notably agitated, yawns frequently, and has multiple episodes of diarrhea. Physical examination reveals diaphoresis, rhinorrhea, and dilated pupils. Which of the following is the most likely diagnosis?

A. Benzodiazepine withdrawal
B. Hallucinogen intoxication
C. Opioid withdrawal
D. Stimulant intoxication

C. Opioid withdrawal

32-year-old man presents to your clinic after losing his job because he was intoxicated while working. He has been drinking daily since he was 16 years old. He was able to complete college and went to work full-time right after graduation but has lost several jobs since. His wife has threatened to divorce him if he does not get help.
Which of the following medications would be the most useful as a behavioral modifier to decrease his alcohol use?

A. Acamprosate
B. Disulfiram
C. Flumazenil
D. Naltrexone

B. Disulfiram

Which of the following statements best describes the use of medication in control of agitated and aggressive behaviors in older adults with major neurocognitive disorders?

A. Although used in practice, there is a risk of increased death with antipsychotics

B. The best evidence is for the use of cognitive enhancers to reverse the disease process

C. The FDA has indicated that antipsychotics are safe first-line options

D. Non-pharmacological interventions are generally not effective

A. Although used in practice, there is a risk of increased death with antipsychotics

The Psychiatric Nurse Practitioner is treating a 12-year-old for attention deficit hyperactivity disorder. The parents ask for a trial of a non-stimulant for their child. Which of the following is not an appropriate order?

A. Strattera 25 mg
B. Clonidine 0.1 mg daily
C. Guanfacine ER 1 mg daily
D. Adderall 10 mg daily

D. Adderall 10 mg daily

Which of the following medications is associated with the highest incidence of erectile dysfunction?

A. Lamotrigine
B. Clonazepam
C. Paroxetine
D. Doxepin

C. Paroxetine

A 45-year-old male has been diagnosed with depression, anxiety, and antisocial personality disorder (ASPD). He has a history of substance abuse and suicidal behavior, including attempted medication overdoses.

Which of the following medications would be the safest and most efficacious option to treat this patient’s mental health disorders?

A. Fluoxetine
B. Amitriptyline
C. Alprazolam
D. Buspirone

A. Fluoxetine

Gold standard tx for BPD?

 Gold standard = Dialectical behavior therapy (DBT)

Antisocial personality disorder begins as what in childhood?

Conduct disorder

Effect of _________ use in the elderly = Anticholinergic (dry mouth, confusion, blurred vision, urinary retention, constipation, etc.)

Always review medications and be cautious of this.

“Coge-“

Cogentin (benztropine)

Regarding normal _____:

Decreased protein levels = more free meds in the body = risk for toxicity

“agi-“

aging

Regarding normal aging:

Consider _______ = MDD w/ symptoms of insomnia and decreased appetite

“Rem-“

Remeron

Promotes synaptic plasticity

“mema-“

Memantine

DO NOT USE WITH PREEXISTING CARDIAC CONDITIONS & SYMPTOMS
FDA approved for children 6+

“methyl-“

Methylphenidate (Ritalin, Concerta)

Psychotherapy (CBT)
Treat comorbid anxiety or depression

Treatment for which personality disorder?

“ob-“

Obsessive

Patients on what medication for smoking cessation treatment should be observed for neuropsychiatric symptoms including changes in behavior, hostility, agitation, depressed mood, and suicide-related events, including ideation, behavior, and attempted suicide.

“bupro-“

bupropion

First-line treatment for personality disorders is _____________,

“psyc-“

psychotherapy

Symptom-focused, medication treatment of personality disorders is generally considered to be an adjunct to psychotherapy.
Avoid prescribing medications that can be fatal in overdose, such as __________ antidepressants

“tric-“

tricyclic

Do not administer disulfiram until the person has been alcohol free at least __ hours.

Pay attention to MOA buprenorphine –> mu receptor _______ ________

“par- agon-“

partial agonist

Lewy body dementia people? Answer: they are very sensitive to _____________

“antip-“

antipsychotics

Frontal temporal dementia ppl what do you give them for disinhibition? Ans: ____ class meds

“SS-“

SSRI

What is one form of Naltrexone delivery method limited to inpatient use?

“im-“

implant

What is the mechanism of action buprenorphine?

“mu rec- par- ago-“

Mu receptor partial agonist for opioid withdrawal

What medication taken too soon after last opioid use increases the chances of intense withdrawal that comes on very quickly (precipitated withdrawal)?

“bupren-“

buprenorphine

Nausea and vomiting;
Diarrhea;
Dehydration;
Irritability;
Restlessness;
Yawning;
Twitching;
Increased heart rate and blood pressure;
Chills;
Increased temperature;
Rhinorrhea;
Lacrimation;
Dilated pupils

Opioid intoxication or opioid withdrawal?

Opioid withdrawal

Nausea and vomiting;
Respiratory depression;
Constipation;
Itching;
Mioisis (small pupil);
Euphoria; and
Sedation

Opioid intoxication or opioid withdrawal?

Opioid intoxication

What medication is given for opioid intoxication during cardiac or respiratory depression is a concern?

“nalo-“

Naloxone

What would NOT be the treatment for chest pain and MI from cocaine?

“beta-“

Beta blockers are to be avoided due to unopposed a-adrenergic stimulation.

What class of drugs are to be avoided for acute alcohol intoxication?

“benz-“

benzodiazepines

What medications can you give for patients with hepatic dysfunction?

“oxaz- and lora-“

oxazepam and lorazepam

What are the treatments for alcohol withdrawal symptoms?

Diazepam intravenous;
Lorazepam intravenous or intramuscular;
Thiamine intravenous or intramuscular;
Addressing electrolyte imbalances

What are the treatments for DT?

Acute care management;
Parenteral diazepam or lorazepam;
Thiamine;
Antipsychotics if necessary

What is the mechanism of action of disulfiram?

Via negative reinforcement, where drinking is avoided due to unpleasant effects.

What is the mechanism of action of Acamprosate?

NMDA receptor antagonist

How is Acamprosate cleared?

“rena-“

renally

What medication can be given to patients with AUD with hepatic dysfunction?

“acam-“

acamprosate (Campral)

What medication is suitable for AUD with comorbid OUD?

“nalt-“

Naltrexone

What medication only deals with physical dependence, but does not address the psychological component of smoking?

“nico-“

NRT

What are the “Very Bad Cancer” medications?

“vare-, bupro-, clon-“

Varenicline;
Bupropion;
Clonidine

What medication for smoking cessation treatment should be observed for neuropsychiatric symptoms that include changes in behavior, hostility, agitation, depressed mood, and suicide-related events that include ideation, behavior, and attempted suicide?

“bupro-“

bupropion

What medications can treat agitation in patients with dementia?

“atyp- antip-“

atypical antipsychotics

What type of medications are used only for short-term and acute episodes of aggression, agitation, and psychosis in patients with dementia?

“benz-“

benzodiazepines

What medical emergency can be caused with TCAs, anticholinergics, benzodiazepines, non-benzodiazepines, corticosteroids, H2 blockers, and opioids in elderly patients?

“delir-“

delirium

A type of frontotemporal degeneration (FTD) that results from bilateral lesions of the medial temporal lobe and manifests with hypersexuality and hyperorality.

“kluv-“

Kluver-Bucy syndrome

What type of medications are appropriate for mild to moderate dementia?

“Damn, Grandma’s Regressing”

“don-, riva-, gala-“

Donepezil;
Rivastigmine;
Galantamine
“Damn, Grandma’s Regressing”

Which TCA has the fewest anticholinergic effects?

“nort-“

Nortriptyline

What TCA is the most appropriate in the elderly?

“nort-“

Nortriptyline

What type of medications are preferred in the elderly?

“SS-“

SSRIs

What medication is the most appropriate for elderly patients with MDD, insomnia, and decreased appetite?

“mirt-“

mirtazapine

What medication is the best alternative to sedative-hypnotic use for insomnia in the elderly as it is less likely to cause memory impairment, paradoxical excitement, or rebound insomnia?

“traz-“

trazodone

What are the “Man, ADHD Does Damage” medications?

“meth-, amp-, dexm-, dext-“

Methylphenidate;
Amphetamine salts;
Dexmethylphenidate;
Dextroamphetamine

What are the 5 non-stimulants for treating ADHD?

“TC-, clon-, guan-, bupro-, atom-“

TCAs;
Clonidine;
Guanfacine;
Bupropion;
Atomoxetine

What are the “Calm Teens Give Better Answers” medications?

“TC-, clon-, guan-, bupr-, atom-“

TCAs;
Clonidine;
Guanfacine;
Bupropion;
Atomoxetine

What types of stimulants are used when patient needs a duration of action longer than 4 hours, improves adherence, and is less likely to be abused?

“inter- or long-“

intermediate or long-acting

What symptom do children exhibit that requires blood pressure and heart rate monitoring?

“dizz-“

dizziness

If dizziness in children occurs at peak, what should the patient be switched to?

“long- form-“

A longer acting formula

If a patient exhibits this stimulant associated symptom, they should be switched to a shorter acting formula?

“inso-“

insomnia

Prior to starting a stimulant, the patient history, family history, and exam should be conducted with a focus on what?

“card-“

cardiovascular

What stimulant side effect may require discontinuation of medication?

“ti-“

tics

What condition is pharmacological treatment initiated as first-line therapy after careful assessment and targets co-occurring disorders?

“inte- dis-“

intellectual disability

What medications should not be combined with stimulants?

“SN-, moo- sta-, MA-, antip-, TC-“

SNRIs;
Mood stabilizers;
MAOIs;
Antipsychotics;
TCAs

What medications are “Stimulants Make Me Act Tense?”

“SN-, moo- sta-, MA-, antip-, TC-“

SNRIs;
Mood stabilizers;
MAOIs;
Antipsychotics;
TCAs

What non-stimulant ADHD medication is most appropriate in a patient with co-occurring depression?

“bupro-“

bupropion

What type of medication class is considered a “reasonable choice” in a patient with co-occurring depression and anxiety?

“TC-“

TCAs

What 2 medications are approved by the FDA to treat severe behavioral issues in ASD, specifically tantrums, self-injury, and aggression?

“risp-, arip-“

risperidone, aripiprazole

What is the on-demand treatment for premature ejaculation?

“clom-“

clomipramine

What medication, if combined with nitrates, can cause an unsafe drop in blood pressure, headaches, flushing, and dizziness?

“sild-“

sildenafil

What is the most appropriate medication for a female with depression and hyperarousal?

“bupro-“

bupro-“

What SSRI is most likely to cause sexual dysfunction?

“parox-“

paroxetine

What SSRI may be used to treat premature ejaculation?

“parox-“

paroxetine

What can be done to reduce sexual side effects caused by psychotropic medications?

“dos- red-“

dose reduction

What is a Cluster B personality disorder that begins as a conduct disorder in childhood?

“antiso-“

antisocial

What is the gold-standard treatment for borderline disorder?

“dial-“

dialectical behavior therapy (DBT)

What class of medications are strongly discouraged in treating BPD due to risks of worsening impulsivity and suicidality?

“benz-“

benzodiazepines

What type of treatment is not recommended when treating the primary traits of antisocial personality disorder?

“pharm-“

pharmacological

What is the treatment for male hypoactive sexual desire disorder and female sexual interest/arousal disorder?

“horm-“

hormone replacement therapy

Guanfacine is an alpha 2 agonist.

True or False?

True

What is the first-line medication for tic disoder?

“guan-“

guanfacine

What are the first-line treatments options for enuresis?

“desmo-, imipr-“

desmopressin, imipramine

What is the management of IDD deficits?

“beha- ther-“

behavioral therapy

What stimulant medication is FDA approved for children 6+ that should not be used in patients with pre-existing cardiac conditions?

“methyl-“

methylphenidate

What FDA stimulant is approved for children 3+?

“dextrome-“

dextromethylphenidate

What non-stimulant is approved for children aged 6-17?

“guan-“

guanfacine

What is the mechanism of action of Naloxone?

Pure opioid antagonist that competes and displaces opioids receptor sites.

____________ is sometimes thought of as a temporary measure. Its use in opiate abstinence is also called medication-assisted treatment (MAT) with suboxone may be lifelong rather than bridge therapy to be discontinued when the addiction is stabilized. Because low endogenous opioid availability is implicated in not only the pain response but also hypothetically in mood states, impulsivity, aggression, and even autism, ongoing MAT has the potential to improve outcomes for patients long-term.

“subo-“

Suboxone

Differentiation between delirium and dementia is also important and can usually be distinguished by the relatively _____ onset of symptoms with delirium vs gradual progression with dementia.

“rap-“

rapid

For delirium, give ______________.

“hal-“

Haldol

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