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Clinical Therapeutics 2 > Opioids - Addiction > Flashcards

Opioids - Addiction Flashcards

1
Q

what is addiction medicine about?

A

changing people’s behaviors

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2
Q

why are people dying from heroin?

A

bc of fentanyl (people think it’s heroin, but it’s not)

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3
Q

FDA issued BBW for what combo of drugs?

A

don’t combine BENZO’S + OPIOIDS -> LETHAL

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4
Q

what is the scoring for DSM V substance Use Disorder Dx Criteria? (Mild, Moderate, Severe)

A

Mild = 2-3

Moderate = 4-5

Severe = 6 or more

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5
Q

what’s the 4 groups for DSM V substance use disorder dx criteria?

A

Impaired control

Social impairment

Risky use

Pharm dependence

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6
Q

what criteria makes up the IMPAIRED CONTROL group for DSM V substance use disorder dx criteria?

A

(1) Larger amounts or longer than intended
(2) Attempts to quit or control use (but failed)
(3) Much time spent using or recovering
(4) Cravings

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7
Q

what criteria makes up the SOCIAL IMPAIRMENT group for DSM V substance use disorder dx criteria?

A

(1) Inability to meet responsibilities at home, school, employment
(2) Interpersonal/relationship problems
(3) Given up or cutting back on pleasurable activities

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8
Q

what criteria makes up the RISKY USE group for DSM V substance use disorder dx criteria?

A

(1) Placed oneself in danger to use

(2) Use resulting in physical or psychological illness/harm

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9
Q

what criteria makes up the PHARM DEPENDENCE group for DSM V substance use disorder dx criteria?

A

(1) Tolerance

(2) Withdrawal

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10
Q

does withdrawal = addiction?

A

NO!!!

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11
Q

what will everyone on Rx opioids have if on them long enough? reason why they are hard to distinguish from what?

A

Tolerance and Withdrawal (reason why they are hard to distinguish from addiction)

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12
Q

what 2 criteria int he substance use disorder are excluded when evaluating someone for a Rx opioid disorder?

A

Tolerance and withdrawal (don’t look at them in terms of the dx)

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13
Q

what is not necessary nor sufficient for dx of opioid use disorder dx?

A

Physical dependence/tolerance to opioids

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14
Q

when do you include tolerance and withdrawal criteria in the dx of opioid use disorder?

A

when pt is using heroin

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15
Q

how do you talk to patients to dx them with substance use d/o?

A

Motivational Interviewing - teaches you how to TALK to people in a way that motivates CHANGE

don’t just ask pt questions from a list -> they will say NO

THESE PTS WANT TO HAVE A CONVO -> EASIEST WAY TO DX THEM

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16
Q

what are the 3 main signs of opioid withdrawal?

A

Piloerection (goosebumps), Mydriasis (dilated pupils), Yawning

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17
Q

criteria for dx of opioid withdrawal has everything to do with the ____

A

HISTORY

  • stopped/cut back on opioid recently
  • running out of rx pills
  • not being able to find rx pills
  • not using heroin last 12-24hrs
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18
Q

when looking for opioid withdrawal, what type of findings do you want to look for? (subjective or objective?)

A

OBJECTIVE FINDINGS

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19
Q

what is the COWS scale?

A

takes the withdrawal sx’s and creates a score (mild, moderate, severe)
-important in terms of tx

NOT A DX TOOL -> IT’S A SEVERITY TOOL

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20
Q

what must be made first before doing the COWS scale?

A

opioid withdrawal dx

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21
Q

can Methadone/Suboxone be given in the hospital legally?

A

YES!!! - in the inpatient setting you can give methadone if the pt has been admitted for some OTHER DX

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22
Q

why treat an opioid withdrawal?

A

(1) permits focus on acute medical problem requiring hospitalization
(2) decreases leaving against medical advice
(3) FACILITATES OPEN DISCUSSION ABOUT ADDICTION
(4) HELPS FACILITATE REFERRAL TO SUBSTANCE USE D/O TX AFTER HOSPITALIZATION

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23
Q

what are the full agonists?

A

Morphine, Oxycodone, Methadone

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24
Q

what is the partial agonist?

A

Buprenorphine

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25
what are the antagonists?
Naloxone, Naltrexone
26
what is Vivitrol?
IM injection of Naltrexone - approved for opioid and alcohol abuse
27
approach to treating opioid withdrawal = approach to treating ___
addiction
28
what are the comfort meds for withdrawal?
Clonidine, NSAIDs, Benzos, Dicyclomine, Bismuth subsalicylate or other anti-diarrheals
29
what does Clonidine that for opioid withdrawal?
hyperadrenergic state
30
what do NSAIDs treat for opioids withdrawal?
muscle cramps/pain
31
what do Benzo's that for opioid withdrawal?
insomnia
32
do NOT combine Benzo's with ___ or ____
methadone or buprenorphine DON'T COMBINE BENZO'S WITH OPIOIDS - BBW
33
what does Dicyclomine treat for opioid withdrawal?
abdominal cramps
34
what is a Methadone?
a full opioid agonist
35
is Methadone a natural opioid or a synthetic opioid?
synthetic opioid
36
what are the 3 main real opiates? where do they come from?
Codeine, Morphine, Diacetylmorphine (heroin) | -they come from POPPY plant
37
do synthetic opiates make urine drug screen positive for opiates?
NO!!! - MUST CHECK SPECIFICALLY FOR METHADONE OR OTHER SYNTHETIC OPIATES TO KNOW!!!
38
onset of action for PO Methadone?
30-60min
39
duration of action for Methadone in: - treating opioid addiction - treating pain
- treating opioid addiction: 24-36hrs | - treating pain: 6-8hrs (TID dosing)
40
dosing for Methadone (acute withdrawal; cravings and "opioid blockade")
acute withdrawal: 20-40mg craving and "opioid blockade": >60mg, often >80mg
41
what is Subutex? given to who?
Buprenorphine ("mono") | -given to pregnancy pts
42
what med do pregnancy pts get prescribed?
Buprenorphine ("mono")
43
what is Suboxone?
Buprenorphine + Naloxone ("combo")
44
Buprenorphine is what schedule drug?
schedule 3
45
how MUST Buprenorphine be taken?
SL
46
what's the affinity of Buprenorphine for the opioid receptor? dissociation?
very high affinity for opioid receptor slow dissociation
47
what is the ceiling effect for Buprenorphine?
ceiling effect for respiratory depression
48
what is the MOA of Buprenrphine?
HIGH AFFINITY, PARTIAL AGONIST
49
do patient's typically have euphoria from Buprenorphine?
NO!!!
50
can other opioids bind to mu receptor if Buprenorphine is already present not he mu receptor?
NO!!! - THEY CAN'T B/C OF BUPRENORPHINE'S HIGH AFFINITY TO THE MU RECEPTOR
51
what MUST pt be in, in order for them to start Buprenorphine?
Withdrawal OR Opioid Naive and have an opioid use disorder (ex: release from incarceration)
52
if pts are NOT in withdrawal when start Buprenorphine, what will happen?
they will get withdrawal effects b/c Buprenorphine will knock off current opioid on mu receptor and it only has PARTIAL AGONIST EFFECTS
53
what's the point of having Naloxone in combo with Buprenorphine?
to reduce its street value/misuse potential b/c don't get effect from Naloxone or if crush up Suboxone then get withdrawal effects
54
what is bioavailability for Buprenorphine?
GOOD sublingual and IV bioavailability POOR GI bioavailability (can't take PO)
55
what is the bioavailability for Naloxone?
GOOD IV bioavailability POOR GI (can't take PO) and SL bioavailability
56
the combo of Buprenorphine and Naloxone (Suboxone) results in decreased what?
decreased abuse and diversion for IV use
57
what is naltrexone similar to?
naloxone, but has PO bioavailability
58
how do you treat opioid withdrawal w/METHADONE in hospital on Day 1?
(1) Dx and assess severity of acute opioid withdrawal (COWS) (2) Give methadone (10-20mg solution x 1) (3) Re-evaluate pt q2-3hrs (4) Give 5-10mg additional doses of methadone q2-3 hrs until withdrawal is relieved -> DO NOT EXCEED 40mg METHADONE IN FIRST 24HRS
59
what dose of methadone can you not exceed in first 24hrs of withdrawal tx?
40mg
60
when do you NOT give additional doses of methadone in withdrawal tx?
if sedation or respiratory depression (< 8 breaths/min) develop, regardless of COWS score
61
how do you opioid withdrawal w/METHADONE in hospital on Day 2?
(1) Morning of Day 2, give total daily dose from day 1 (NOT >40mg) (2) Discuss options w/pt for rest of hospital stay (3) Do not provide Rx for methadone at discharge (can only do so if methadone clinic or opioid tx program)
62
what are the pts options for rest of hospital stay in tx of opioid withdrawal on Day 2? (3 options)
- continue daily methadone w/last dose given on day of discharge - taper methadone 5-10mg /day w/last dose given on day of discharge (don't prolong hospitalization to complete the taper) - Referral to long-term substance use disorder tx
63
how do you treat opioid withdrawal with BUPRENORPHINE in the hospital?
- pts MUST be in withdrawal - COWS >8 or greater with objective signs (mydriasis, sweats, piloerection) - MUST BE free of short acting opioids (heroin, oxy) for 12-24hrs and LONGER for long-acting opioids (methadone, MS Contin)
64
how do you treat opioid withdrawal with BUPRENORPHINE in the hospital?
- pts MUST be in withdrawal - COWS >8 or greater with objective signs (mydriasis, sweats, piloerection) - start 2-4mg of buprenorphine combine w/naloxone 0.5-1mg - Re-evaluate 90min w/COWS - provide additional 2-4mg of buprenorphine
65
how long must pt be opioid free to be treated with Buprenorphine for withdrawal? (free of short acting opioids and longer acting opioids)
MUST BE free of short acting opioids (heroin, oxy) for 12-24hrs and LONGER for long-acting opioids (methadone, MS Contin) - might need to wait 1 day or 2
66
what is the starting dose of buprenorphine + naloxone for opioid withdrawal?
start 2-4mg of buprenorphine combine w/naloxone 0.5-1mg
67
does detox work alone?
NO!!!
68
when people leave detox they have lost their ___
tolerance
69
heroin overdoses go way down when increase access to what?
to methadone
70
what are the goals of maintenance therapies for opioid use disorder?
alleviate withdrawal, eliminate drug cravings and opioid use, opioid blockade (may help change behavior) NORMALIZE BRAIN REWARD PATHWAYS AND BEHAVIOR
71
maintenance therapy for opioid use d/o reduces risk of what infectious disease complications?
HCV, HIV, endocarditis, bacteremia
72
what is the MOA of naltrexone?
pure opioid antagonist
73
what is the duration of action for oral naltrexone?
24-48 hours
74
in order for pts to use injectable naltrexone (Vivitrol), they must be opioid free for a minimum of how many days? why is this hard?
7-10 days before tx ***hard to get people started
75
Naltrexone is mostly commonly used in what settings?
institutional settings
76
injectable naltrexone has comparable outcomes to ___
buprenorphine
77
what is naloxone? MOA?
full antagonist w/strong affinity for the mu receptor reverses opioid overdose by displacing opioid agonist (ex: heroin) from the receptor will induce withdrawal sx's if opioids remain on receptor when given
78
people that chronically use opioids don't have any what to opioids? they use opioids to feel what?
don't have any euphoria to opioids they use opioids to feel "normal"
79
what is the entire point of opioid agonist therapy?
to keep people in their normal phase long enough until their behaviors change and their dopaminergic system REWIRES -then can remove the methadone or buprenorphine slowly over time
80
in order to get methadone maintenance tx, the pt needs to do what?
come to clinic every day METHADONE MAINTENANCE TX IS HIGHLY STRUCTURED
81
Methadone increases...
overall survival, treatment retention, employment, and improves birth outcomes
82
Methadone decreases...
illicit opioid use, hepatitis and HIV seroconversion, and criminal activity
83
downfall of Methadone maintenance?
``` Methadone is hard to find highly regulated (need methadone clinic) limited access lack of privacy can't "graduate" from program stigma ```
84
how do physicians become qualified to administer Methadone for maintenance therapy?
must be certified in addiction psychiatry or medicine Complete eight hours of training MUST HAVING TRAINING + WAIVER FROM DEA TO GET ANOTHER DEA #
85
at what effect does Buprenorphine level off? what does this mean? what is this not true with?
at withdrawal relief -means pt doesn't get euphoria, respiratory depression, or overdose death from buprenorphine CAN PUSH DOSE OF BUPRENORPHINE PRETTY HIGH AND WON'T GET THOSE BAD EFFECTS -> "CEILING EFFECT" ***not drug with methadone
86
Buprenorphine is available in what settings?
primary care settings
87
maintenance tx with Buprenorphine is less effective than?
methadone (b/c methadone has no dose limit -> make methadone dangerous)
88
what makes Methadone dangerous?
the fact that it DOESN'T have a "ceiling effect" -> will experience euphoria, respiratory depression, and death at high doses
89
what must you tell pts about if you are prescribing them opioids?
Naloxone (Narcan)
90
Narcan distribution in areas where there was no narcan decreased what?
overdose death rate
91
what are the semi-synthetic opioids? what do they do to drug screen? created from what?
hydromorphone, hydrocodone, oxycodone, oxyomorphone -created from natural opiates or morphine esters may or may not turn opiate screen positive
92
what are the synthetic opioids? what do they do to drug screen?
- Fentanyl - Tramadol - Methadone - Buprenorphine NEVER TURN DRUG SCREEN POSITIVE
93
what is Fentanyl? what drug schedule is it?
fully synthetic opioid, schedule 2
94
how much more potent than heroin is Fentanyl?
50-100x more potent
95
what is acetyl fentanyl? more potent that what, but less potent than what?
illicitly produced fentanyl analog more potent than heroin, but less potent than fentanyl
96
what's so bad about fentanyl?
fentanyl overdoses are acute and severe -> occur in seconds to minutes
97
Most overdose deaths involve what drug?
fentanyl
98
what are the 3 different meds for maintenance therapy for opioid use d/o?
Methadone (long-acting full agonist) Buprenorphine (partial agonist) Naltrexone - PO - IM = Vivitrol

Clinical Therapeutics 2 (11 decks)

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