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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
Q

what are the antagonists?

A

Naloxone, Naltrexone

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26
Q

what is Vivitrol?

A

IM injection of Naltrexone - approved for opioid and alcohol abuse

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27
Q

approach to treating opioid withdrawal = approach to treating ___

A

addiction

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28
Q

what are the comfort meds for withdrawal?

A

Clonidine, NSAIDs, Benzos, Dicyclomine, Bismuth subsalicylate or other anti-diarrheals

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29
Q

what does Clonidine that for opioid withdrawal?

A

hyperadrenergic state

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30
Q

what do NSAIDs treat for opioids withdrawal?

A

muscle cramps/pain

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31
Q

what do Benzo’s that for opioid withdrawal?

A

insomnia

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32
Q

do NOT combine Benzo’s with ___ or ____

A

methadone or buprenorphine

DON’T COMBINE BENZO’S WITH OPIOIDS - BBW

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33
Q

what does Dicyclomine treat for opioid withdrawal?

A

abdominal cramps

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34
Q

what is a Methadone?

A

a full opioid agonist

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35
Q

is Methadone a natural opioid or a synthetic opioid?

A

synthetic opioid

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36
Q

what are the 3 main real opiates? where do they come from?

A

Codeine, Morphine, Diacetylmorphine (heroin)

-they come from POPPY plant

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37
Q

do synthetic opiates make urine drug screen positive for opiates?

A

NO!!! - MUST CHECK SPECIFICALLY FOR METHADONE OR OTHER SYNTHETIC OPIATES TO KNOW!!!

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38
Q

onset of action for PO Methadone?

A

30-60min

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39
Q

duration of action for Methadone in:

  • treating opioid addiction
  • treating pain
A
  • treating opioid addiction: 24-36hrs

- treating pain: 6-8hrs (TID dosing)

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40
Q

dosing for Methadone (acute withdrawal; cravings and “opioid blockade”)

A

acute withdrawal: 20-40mg

craving and “opioid blockade”: >60mg, often >80mg

41
Q

what is Subutex? given to who?

A

Buprenorphine (“mono”)

-given to pregnancy pts

42
Q

what med do pregnancy pts get prescribed?

A

Buprenorphine (“mono”)

43
Q

what is Suboxone?

A

Buprenorphine + Naloxone (“combo”)

44
Q

Buprenorphine is what schedule drug?

A

schedule 3

45
Q

how MUST Buprenorphine be taken?

A

SL

46
Q

what’s the affinity of Buprenorphine for the opioid receptor? dissociation?

A

very high affinity for opioid receptor

slow dissociation

47
Q

what is the ceiling effect for Buprenorphine?

A

ceiling effect for respiratory depression

48
Q

what is the MOA of Buprenrphine?

A

HIGH AFFINITY, PARTIAL AGONIST

49
Q

do patient’s typically have euphoria from Buprenorphine?

A

NO!!!

50
Q

can other opioids bind to mu receptor if Buprenorphine is already present not he mu receptor?

A

NO!!! - THEY CAN’T B/C OF BUPRENORPHINE’S HIGH AFFINITY TO THE MU RECEPTOR

51
Q

what MUST pt be in, in order for them to start Buprenorphine?

A

Withdrawal

OR

Opioid Naive and have an opioid use disorder (ex: release from incarceration)

52
Q

if pts are NOT in withdrawal when start Buprenorphine, what will happen?

A

they will get withdrawal effects b/c Buprenorphine will knock off current opioid on mu receptor and it only has PARTIAL AGONIST EFFECTS

53
Q

what’s the point of having Naloxone in combo with Buprenorphine?

A

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
Q

what is bioavailability for Buprenorphine?

A

GOOD sublingual and IV bioavailability

POOR GI bioavailability (can’t take PO)

55
Q

what is the bioavailability for Naloxone?

A

GOOD IV bioavailability

POOR GI (can’t take PO) and SL bioavailability

56
Q

the combo of Buprenorphine and Naloxone (Suboxone) results in decreased what?

A

decreased abuse and diversion for IV use

57
Q

what is naltrexone similar to?

A

naloxone, but has PO bioavailability

58
Q

how do you treat opioid withdrawal w/METHADONE in hospital on Day 1?

A

(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
Q

what dose of methadone can you not exceed in first 24hrs of withdrawal tx?

A

40mg

60
Q

when do you NOT give additional doses of methadone in withdrawal tx?

A

if sedation or respiratory depression (< 8 breaths/min) develop, regardless of COWS score

61
Q

how do you opioid withdrawal w/METHADONE in hospital on Day 2?

A

(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
Q

what are the pts options for rest of hospital stay in tx of opioid withdrawal on Day 2? (3 options)

A
  • 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
Q

how do you treat opioid withdrawal with BUPRENORPHINE in the hospital?

A
  • 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
Q

how do you treat opioid withdrawal with BUPRENORPHINE in the hospital?

A
  • 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
Q

how long must pt be opioid free to be treated with Buprenorphine for withdrawal? (free of short acting opioids and longer acting opioids)

A

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
Q

what is the starting dose of buprenorphine + naloxone for opioid withdrawal?

A

start 2-4mg of buprenorphine combine w/naloxone 0.5-1mg

67
Q

does detox work alone?

A

NO!!!

68
Q

when people leave detox they have lost their ___

A

tolerance

69
Q

heroin overdoses go way down when increase access to what?

A

to methadone

70
Q

what are the goals of maintenance therapies for opioid use disorder?

A

alleviate withdrawal, eliminate drug cravings and opioid use, opioid blockade (may help change behavior)

NORMALIZE BRAIN REWARD PATHWAYS AND BEHAVIOR

71
Q

maintenance therapy for opioid use d/o reduces risk of what infectious disease complications?

A

HCV, HIV, endocarditis, bacteremia

72
Q

what is the MOA of naltrexone?

A

pure opioid antagonist

73
Q

what is the duration of action for oral naltrexone?

A

24-48 hours

74
Q

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?

A

7-10 days before tx

***hard to get people started

75
Q

Naltrexone is mostly commonly used in what settings?

A

institutional settings

76
Q

injectable naltrexone has comparable outcomes to ___

A

buprenorphine

77
Q

what is naloxone? MOA?

A

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
Q

people that chronically use opioids don’t have any what to opioids? they use opioids to feel what?

A

don’t have any euphoria to opioids

they use opioids to feel “normal”

79
Q

what is the entire point of opioid agonist therapy?

A

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
Q

in order to get methadone maintenance tx, the pt needs to do what?

A

come to clinic every day

METHADONE MAINTENANCE TX IS HIGHLY STRUCTURED

81
Q

Methadone increases…

A

overall survival, treatment retention, employment, and improves birth outcomes

82
Q

Methadone decreases…

A

illicit opioid use, hepatitis and HIV seroconversion, and criminal activity

83
Q

downfall of Methadone maintenance?

A 
Methadone is hard to find
highly regulated (need methadone clinic)
limited access
lack of privacy
can't "graduate" from program
stigma
84
Q

how do physicians become qualified to administer Methadone for maintenance therapy?

A

must be certified in addiction psychiatry or medicine

Complete eight hours of training

MUST HAVING TRAINING + WAIVER FROM DEA TO GET ANOTHER DEA #

85
Q

at what effect does Buprenorphine level off? what does this mean? what is this not true with?

A

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
Q

Buprenorphine is available in what settings?

A

primary care settings

87
Q

maintenance tx with Buprenorphine is less effective than?

A

methadone (b/c methadone has no dose limit -> make methadone dangerous)

88
Q

what makes Methadone dangerous?

A

the fact that it DOESN’T have a “ceiling effect” -> will experience euphoria, respiratory depression, and death at high doses

89
Q

what must you tell pts about if you are prescribing them opioids?

A

Naloxone (Narcan)

90
Q

Narcan distribution in areas where there was no narcan decreased what?

A

overdose death rate

91
Q

what are the semi-synthetic opioids? what do they do to drug screen? created from what?

A

hydromorphone, hydrocodone, oxycodone, oxyomorphone
-created from natural opiates or morphine esters

may or may not turn opiate screen positive

92
Q

what are the synthetic opioids? what do they do to drug screen?

A
  • Fentanyl
  • Tramadol
  • Methadone
  • Buprenorphine

NEVER TURN DRUG SCREEN POSITIVE

93
Q

what is Fentanyl? what drug schedule is it?

A

fully synthetic opioid, schedule 2

94
Q

how much more potent than heroin is Fentanyl?

A

50-100x more potent

95
Q

what is acetyl fentanyl? more potent that what, but less potent than what?

A

illicitly produced fentanyl analog

more potent than heroin, but less potent than fentanyl

96
Q

what’s so bad about fentanyl?

A

fentanyl overdoses are acute and severe -> occur in seconds to minutes

97
Q

Most overdose deaths involve what drug?

A

fentanyl

98
Q

what are the 3 different meds for maintenance therapy for opioid use d/o?

A

Methadone (long-acting full agonist)

Buprenorphine (partial agonist)

Naltrexone

  • PO
  • IM = Vivitrol

Clinical Therapeutics 2 (11 decks)

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