NSG 552 EXAM 3 Flashcards
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
Drug use that is inconsistent with social use patterns.
“abu-“
Abuse
Reversible syndrome caused by a specific substance affecting memory, judgement, behavior or social or occupational functioning
“intox-“
Intoxication
Substance specific symptoms that occur after stopping or reducing use (opposite of the drug’s intoxication symptoms).
“withd-“
Withdrawal
Needing more of the substance to get the desired effect.
“Tol-“
Tolerance
Reinforcement occurs in the:
“Ven- teg-“ and “Nuc- accu-“
Ventral tegmental area (VTA) and the Nucleus accumbens (Reward center)
Positive rewards of reinforcement= mediated by ____ pathways.
“D-“
DA (dopamine)
____________ release within the reward center is enhanced by the release of natural morphine-like neurotransmitters (Neuropeptides- enkaphalins, beta endorphins).
“Dop-“
DA (dopamine)
Repeated drug use —> ________ system becomes increasingly sensitized.
“Dop-“
DA (dopamine)
Classes of Substance Use Disorders:
Caffeine, nicotine, amphetamines, cocaine, ecstasy
“stim-“
stimulants
Classes of Substance Use Disorders:
Benzodiazepines, Alcohol
“depr-“
depressants
Classes of Substance Use Disorders:
Opioids
“narc-“
narcotics
Classes of Substance Use Disorders:
Lysergic acid diethylamide (LSD) Marijuana
“hall-“
hallucinogens
- 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
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
________ withdrawal: Insomnia, Irritability, Hand tremor
“mil-“
mild
________ withdrawal: Autonomic hyperactivity (diaphoresis, tachy, HTN), Fever
“mod-“
moderate
________ withdrawal: Seizures (12-48 hours post consumption); Hallucinations; Delirium Tremens (48-96 hours after last drink)
“sev-“
severe
Alcohol Withdrawal delirium: Initial treatment is a ___________.
Careful with the use of antipsychotics because they lower the seizure threshold.
“benz-“
benzodiazepine
____________________: Initial treatment is a benzodiazepine.
Careful with the use of antipsychotics because they lower the seizure threshold.
“alc- wit- del-“
Alcohol Withdrawal delirium
Alcohol Withdrawal delirium: Initial treatment is a benzodiazepine.
Careful with the use of antipsychotics because the lower the _______ threshold.
“seiz-“
seizure
Alcohol Withdrawal delirium: Initial treatment is a benzodiazepine.
Careful with the use of _____________ because the lower the seizure threshold.
“anti-“
antipsychotics
- 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])
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)
Functions as “artificial alcohol” by reducing glutamate activity.
Which med is this?
“acamp-“
acamprosate (Campral)
Reduces neuronal hyperactivity during early alcohol recovery – helps sustain abstinence.
Which med is this?
“acamp-“
acamprosate (Campral)
Likely modulates glutamate transmission
Which med is this?
“acamp-“
acamprosate (Campral)
First line treatment in maintaining abstinence after detox
Which med is this?
“acamp-“
acamprosate (Campral)
Used for relapse prevention (post detoxification)
Which med is this?
“acamp-“
acamprosate (Campral)
Can be used in liver disease- not metabolized by the liver (not impacted by ETOH use)
Which med is this?
“acamp-“
acamprosate (Campral)
Can be administered to patients with hepatitis, liver disease and those who continue drinking alcohol
Which med is this?
“acamp-“
acamprosate (Campral)
Contraindicated in severe renal disease.
Which med is this?
“acamp-“
acamprosate (Campral)
Decreases craving – good for individuals who are abstinent or recently relapsed.
Which med is this?
“acamp-“
acamprosate (Campral)
Opioid receptor antagonist
Which med is this?
“nalt-“
naltrexone (Revia, Vivitrol [IM])
Reduces desire/cravings
Which med is this?
“nalt-“
naltrexone (Revia, Vivitrol [IM])
First line treatment – Good for heavy drinkers
Which med is this?
“nalt-“
naltrexone (Revia, Vivitrol [IM])
PO or monthly injection (Vivitrol)- great for patients with non-compliance issues.
Which med is this?
“nal-“
naltrexone (Revia, Vivitrol [IM])
Will precipitate withdrawal in patients with physical opioid dependence.
Which med is this?
“nalt-“
naltrexone (Revia, Vivitrol [IM])
D/C 48-72 hours prior to receiving opiate analgesia.
Which med is this?
“nalt-“
naltrexone (Revia, Vivitrol [IM])
- 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
Blocks enzyme(Aldehyde dehydrogenase) in the liver
Which med is this?
“disul-“
disulfiram (Antabuse)- 2nd line
Causes aversion reaction to ETOH(flushing, headaches, n/v, palpitation, SOB, vertigo, hypotension)
Which med is this?
“disul-“
disulfiram (Antabuse)- 2nd line
Do not administer until the person has been alcohol free at least 12 hours
Which med is this?
“disul-“
disulfiram (Antabuse)- 2nd line
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
Contraindicated in severe cardiac disease, pregnancy, psychosis
Which med is this?
“disul-“
disulfiram (Antabuse)- 2nd line
For highly motivated patients
Which med is this?
“disul-“
disulfiram (Antabuse)- 2nd line
- 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
Potentiates GABA and inhibits Glutamate
Which med is this?
“topi-“
topiramate (Topamax) - 2nd line
Reduces cravings
Which med is this?
“topi-“
topiramate (Topamax) - 2nd line
Remember DOPE-a-max (impaired cognition, nausea, weight loss, metabolic acidosis.
Which med is this?
“topi-“
topiramate (Topamax) - 2nd line
Treatment of withdrawal: (Three benzos to keep patient calm and lightly sedated.
“L, D, and C”
- lorazepam (Ativan)
- diazepam (Valium)
- chlordiazepoxide (Librium)
MOA: Enhance the effects of GABA
Which drug class?
“B-“
Benzodiazepines
Use these three meds in mild withdrawal:
“Gab-, Valp-, and Car-“
- gabapentin (Neurontin)
- valproic acid (Depakene)
- carbamazepine (Tegretol)
Use these three meds in ____ withdrawal:
- gabapentin (Neurontin)
- valproic acid (Depakene)
- carbamazepine (Tegretol)
“mi-“
mild
Three supplements used for nutritional deficiencies in treatment of withdrawal.
“t” “f” “m”
Thiamine, folic acid and multivitamin
These two supplements used to prevent or treat Wernicke’s encephalopathy (B1 deficiency)
“pare- thi-“ and “fol-“
Parenteral thiamine and folate
Another important thing for tx of withdrawal:
“flu” and “ele” balance
Fluid and electrolyte balance
CIWA Score <10 =
“mi-“
mild
CIWA score 10-15 =
“mod-“
moderate
CIWA score 15 =
“sev-“
severe
Banana Bag ingredients (i.e. thiamine, multivitamin, folic acid).
What are we trying to prevent?
“Wern-“
Wernicke’s encephalopathy
__________ blocks reuptake of dopamine, epinephrine and NE = Stimulant effect
“coc-“
Cocaine
- 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
Post intoxication depression “Crash”
- Fatigue
- Malaise
- Hypersomnolence
- Depression
- Anhedonia
- Hunger
- Constricted pupils
- Vivid dreams
What is this?
“coc- with-“
cocaine withdrawal
NO FDA approved med for treatment of which condition?
“coc- with-“
cocaine withdrawal
Off-label med treatment for cocaine withdrawal =
“Nalt-,” “modaf-,” and “Topi-“
Naltrexone, modafinil, Topamax
Supportive care for which condition ?
(control HTN, arrhythmias)
“coc- with-“
cocaine withdrawal
Used for mild-moderate agitation in cocaine withdrawal =
“benz-“
Benzodiazepines
Used for severe agitation or psychosis in cocaine withdrawal:
“antip-“
antipsychotics
___________ 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)
NOTE: Medications for cocaine-induced chest pain and myocardial infarction =
“nitr-“ and “aspi-“
Nitroglycerin, Aspirin
NOTE: Medications for cocaine-induced chest pain and myocardial infarction =
Nitroglycerin, Aspirin
Don’t use which med?
“meto-“
metoprolol (Lopressor)
Often used in dance clubs and raves
“Amp-“
Amphetamines
Have both stimulant and hallucinogenic properties
“Amp-“
Amphetamines
Intoxication is similar to cocaine
“Amp-“
Amphetamines
Can cause ongoing psychosis
“Amp-“
Amphetamines
Withdrawal can cause prolonged depression
“Amp-“
Amphetamines
Txt: Rehydrate, correct electrolyte and treat hyperthermia
“Amp-“
Amphetamines
Intoxication effects of which drug?
- Rage
- Erythema
- Dilated pupils
- Delusions
- Amnesia
- Nystagmus
- Excitation
- Skin dryness
“Phen-“
(Phencyclidine) PCP
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
Regarding which illicit substance?
- No withdrawal
- Recurrence of intoxication due to release of the drug from body lipid stores.
(Phencyclidine) PCP
Nystagmus (Red-bolded) side effect of which drug?
“Phen-“
(Phencyclidine) PCP
The below are part of which drug class?
Benzos, barbiturates, Zolpidem, zaleplon, GHB(date rape drug),
“sed- hyp-“
sedative hypnotics
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
Regarding withdrawal of which drug class?
Abrupt abstinence after chronic use can be life-threatening.
“sed- hyp-“
sedative hypnotics
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
For benzodiazepine OD (a sedative hypnotic) which medication would you use (a benzo antagonist)?
“flu-“
flumazenil
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
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
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
Irritability, anxiety, restlessness, aggression, strange dreams, depression, headaches, insomnia, low appetite
Withdrawal effects of which substance?
“mari-“
marijuana
- Supportive care
- Based on symptoms
Treatment options for which substance?
“mari-“
marijuana
Restlessness
Insomnia
Anxiety
Increased GI motility
Effects from which substance?
“nico-“
nicotine
- Intense craving
- Dysphoria
- Anxiety
- Poor concentration
- Increased appetite
- Weight gain
- Irritability
- Restlessness
- Insomnia
Withdrawal of which substance?
“nico-“
nicotine
Varenicline(Chantix)
- Mimics action of Nicotine
The most effective tobacco cessation - Reduces rewarding aspects
- Prevents withdrawal symptoms
Treatment for which substance?
“nico-“
nicotine
Bupropion (Zyban)
- Inhibits reuptake of dopamine and norepinephrine
- Helps reduce craving and withdrawal symptoms
Treatment for which substance?
“nico-“
nicotine
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
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
This drug class stimulates mu, kappa and delta opiate receptors
Effects on the dopaminergic system which mediates their addictive and rewarding properties
“opio-“
Opioids
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
Flu-like symptoms (body aches, anorexia, rhinorrhea, fever)
Diarrhea
Anxiety
Insomnia
Withdrawal effects of which drug class?
“Opio-“
Opioids
- opium
- heroin
- morphine
- oxycodone
- methadone
- hydrocodone
- codeine
Examples of which drug class?
“Opio-“
Opioids
- 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
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
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
This is regarding which drug class?
“Opio-“
Opioids
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
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
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
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
Decreased mortality with overdose.
Which drug class?
“opi- ago-“
Opioid Agonists (Buprenorphine/Methadone)
- Need to successfully complete opioid withdrawal prior to treatment.
- Precipitates withdrawal in patients actively using opioids
Which drug class?
“opi- ant-“
Opioid Antagonists (Naltrexone)
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
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
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
Opioid Use disorder w/ comorbid pain = this med can be used in managing pain
“sub-“
Suboxone
Inappropriate use of opioids may be an indication that the patient’s pain is uncontrolled.
True or False?
True
Includes psilocybin (mushrooms), mescaline (peyote cactus) and lysergic acid diethylamide (LSD)
“hallu-“
Hallucinogenics
- 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
Do not cause physical dependence or withdrawal
Regarding which kind of substance?
“hallu-“
Hallucinogens
May use Benzos and antipsychotic medications for agitation
Regarding treatment for which kind of substance?
“hallu-“
Hallucinogens
- 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
- 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
- Does not usually occur
- Irritability
- Sleep disturbance
- Anxiety
- Depression
- Nausea/vomiting
- Craving
Withdrawal effects of which kind of substance?
“inha-“
inhalants
Airway monitoring; Chelation depending on solvent
Treatment on the intoxication of which substance?
“inha-“
inhalants
Loss of ability to control the use of inhalants
Regarding which substance?
“inha-“
inhalants
Compulsivity to use inhalants
Regarding which substance?
“inha-“
inhalants
Negative emotional state when not sniffing/breathing inhalants
Regarding which substance?
“inha-“
inhalants
Common among teenagers
Regarding which substance?
“inha-“
inhalants
E.g., volatile solvents, aerosols, gases, nitrites
Regarding which substance?
“inha-“
inhalants
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
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
Emergency effects regarding which substance?
Agitation
Fever
Seizures
Hallucinations
Confusion
Loss of consciousness
Coma
Fatal accidental injury
“inha-“
inhalants
Treatment/management for which substance?
- Treat presenting symptoms
- Benzodiazepines for managing withdrawal and emergency symptoms (e.g., Valium, Lorazepam.
“inha-“
inhalants
This med comes in po, injection and implant (NO LIQUID)
“nalt-“
Naltrexone
- Most-used psychoactive substance in the United States
- Coffee, tea or energy drinks
“caff-“
caffeine
- 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
Occurs if cessation is abrupt
- Headache
- Fatigue
- Irritability
- Nausea
- Vomiting
- Drowsiness
- Muscle pain
- Depression
Withdrawal effects of which substance?
“caff-“
caffeine
Supportive and symptomatic
Treatment for which substance?
“caff-“
caffeine
- 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)
- 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)
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
Alcohol, Cocaine and opioid use disorder can lead to sexual dysfunction.
True or false?
True
Withdrawal seizures are commonly associated with which substances?
“alco-, benz-“
Alcohol, benzodiazepines
- 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
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.
12
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
