Pharmacotherapy of Substance Use Disorders Flashcards
DSM-5, TR Substance Use Disorders
A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by two of the following, occurring in a 12-month period:
Taken in larger amounts or over a longer period than intended
Persistent desire or unsuccessful efforts to cut down or control use
Great deal of time spent in activities necessary to obtain substance or recover from use
Craving, strong desire, or urge to use
Recurrent use results in failure to fulfill major role obligations
DSM-5, TR CONTINUED
Continued use despite consistent or recurrent social or interpersonal problems caused or exacerbated by use or effects of use
Important activities are given up or reduced
Recurrent use in situations in which it is physically
hazardous
Continued use despite knowledge of having a persistent or recurrent physical or psychological problem related to use
Tolerance (needing increased amounts to achieve effect or diminished effect with continued use of the same amount)
Withdrawal (characteristic syndrome OR substance is used to relieve or avoid withdrawal symptoms
Blood Alcohol Concentration
50 mg/dL (0.05mg%): Motor function impairment observable
80 mg/dL (0.08mg%): Moderate impairment, legal definition of intoxication in most states
450 mg/dL: Respiratory depression
500 mg/dL: LD50 for ethanol
STAGES OF ALCOHOL WITHDRAWAL
1-4
Stage 1:
Time of Onset after Withdrawal: ~6-8 hrs
Clinical Features: Moderate autonomic hyperactivity (anxiety, tremulousness, tachycardia, insomnia, nausea, vomiting, diaphoresis) and a craving for alcohol
Stage 2:
Time of Onset after Withdrawal: ~24 hrs
Clinical Features: Autonomic hyperactivity with auditory or visual hallucinations lasting ~ 1 – 3 days – most remain lucid and oriented
Stage 3:
Time of Onset after Withdrawal: ~1-2 days
Clinical Features: ~ 4% of those untreated develop grand mal seizures ~ 7 – 48 hours after drop in BAC
Stage 4:
Time of Onset after Withdrawal: 3-5 days
Clinical Features: Delirium tremens (DTs) in ~5% of patients (confusion, illusions, hallucinations, agitation, tachycardia, hyperthermia)
Mortality associated with DTs ~5 – 15% attributable to arrhythmias, shock, infection, trauma or aspiration
RISK FACTORS FOR DELIRIUM TREMENS
Prior history of DTs
* #1 predictor of future DTs
* Kindling – repeated withdrawal episodes increase the severity of subsequent withdrawal syndromes
Number of detoxifications
Consuming the equivalent of 1 pint of whiskey per day for 10 of 14 days prior to admission
Early symptoms of withdrawal
Hepatic dysfunction
TREATING ALCOHOL WITHDRAWAL
Prohphylaxis/Fixed Dosing
Individualized Dosing
Prophylaxis/Fixed Dosing
Advantage: prevent withdrawal
Disadvantage: unnecessary BZD dosing
Example:
Chlordiazepoxide 25mg TID x 2 days, BID x 2 days, daily x 2 days, then d/c
May also see PRN use of lorazepam to supplement
Individualized Dosing
Use BZD if symptoms warrant: Use CIWA-Ar Scale
CIWA < 8-10: Nonpharmacologic tx
CIWA 8 – 15: Medicate
CIWA > 15: Risk of complications if untreated
Reduces treatment duration, decreased benzodiazepine dosing
Benzodiazepines for treating alcohol withdrawal
No liver dysfunction:
diazepam/chlordiazepoxide; Long t1/2 & ↓ risk of breakthrough symptoms; May also use lorazepam and oxazepam without liver dysfunction
Liver dysfunction: lorazepam, oxazepam
Thiamine
- Always recommend if any suspicion of alcohol use
- Dose: 100mg daily, usually for duration of hospital stay, may be given after discharge, not considered long-term treatment
Phenytoin
not effective to treat withdrawal seizures
Wernicke’s encephalopathy
- Result of thiamine deficiency
- Give before dextrose-containing fluids
- Thiamine is co-factor in glucose metabolism, Wernicke’s can be precipitated by high glucose loads
Disulfiram
Aversive therapy
Unpleasant effects if alcohol is used (flushing, nausea, vomiting, tachycardia)
Potential for cardiovascular collapse, death
Must have highly motivated person
Monitor LFTs
250 mg daily usual maintenance dose
Disulfiram reaction for up to 14 days after d/c
Acamprosate
Maintenance of abstinence
Renal elimination, monitor renal function, avoid in severe renal impairment
Suicidality warning, side effects also include diarrhea, nausea, depression, anxiety
333 mg tablets – 2 tablets (666 mg) three times daily
Is safe to take if the person uses alcohol
Clinical effectiveness is limited by the number of tablets and doses per day
Naltrexone
Decreases binge drinking, helps to increase time between drinking days
Elevated LFTs common, must monitor at baseline and routinely
Need to evaluate pain management needs, patient should have wallet card or be able to tell emergency providers that they are taking this
Warning for injection site reactions
Symptoms of Opioid Withdrawal
Muscle Aches/Tension
Agitation/Anxiety/Insomnia
Diarrhea
Abdominal Cramping/Nausea/Vomiting
Sweating/yawning/increased tearing/runny nose
Short-term tapering doses of opioids or buprenorphine may be used in the withdrawal period
Symptoms of Opioid Withdrawal: muscle aches/tension treatment
acetaminophen or NSAID
Symptoms of Opioid Withdrawal: agitation/anxiety/insomnia treatment
hydroxyzine/benzodiazepines
Symptoms of Opioid Withdrawal: abdominal cramping/nausea/vomiting treatment
ondansetron
Symptoms of Opioid Withdrawal: diarrhea treatment
loperamide
