psych packet 4 Flashcards
alcoholism/substance disorders
TREATMENT
- No panacea out there
- Many tmts for substance disorders proven effective in clinical trials
- Use assessment results to pick tmt strategies: “treatment matching”.
- PA in primary care: decides if a brief intervention is enough or does the pt need specialized treatment
- Referral
o Specialized tmt indicated for moderate to severe problems
o Substance dependence
o Problems complicated by significant psychiatric or medical comorbidities
- Family
o Patients family suffers as well
o Referral to Al-Anon or Nar-Anon may help
§ Family members learn that they did not cause pt.’s problems
§ They cannot control the problem
§ They cannot cure it
- Treatment goals:
o Abstinence
§ Most tmt facilities
§ Severe problems
§ Dependence
§ Any illicit substance
pharmacologic adjuncts
1. Only adjuncts to treatment
2. ______ (Antabuse) : for motivated pts with alcoholism in other aspects of recovery
o Blocks breakdown of _____
o Causes acetaldehyde to accumulate
o Hypotension, tachycardia, dizziness, weakness, flushing, sweating, N/V, headache and neck ache, chest pain, palpitations, dyspnea, blurred vision, confusion, syncope
3. _______
o More alcohol consumed, more severe the reaction, even to cardiac collapse
o Contraindicated in pts with severe ______
o Disulfiram-induced hepatitis can be fatal; liver function (AST) results taken at baseline, in 2-4 weeks, monthly for 2 months, quarterly for 1 year, then q 6 mos.
o Hold it if AST is more than 3 Xs normal
o Other side effects: optic neuritis, peripheral neuropathy
o Psychosis in high doses (> 500 mg) or when combined with metronidazole (Flagyl) or isoniazid (INH)
o May increase phenytoin (Dilantin) levels and PT time with anticoagulants
o Avoid topical use and ingestion of all alcohol containing products
o Delayed disulfiram-alcohol reaction: 10-14 days post stopping therapy
o Start: 250 mg/d
o Don’t start until BAL is zero; (24 hrs. post last drink)
4. _______ (ReVia)
o Adjunctive tmt for either ____ dependence or ETOH dependence
o Acts like long-acting naloxone (Narcan)
o Competitively blocks opioid receptors
o If opioid addict relapses, no euphoria experienced; they can call for help
o Does not block ______
o If user is active, causes acute withdrawal
o Only use if urine drug screen negative for opioids (7-10 days post last use)
o Initial test dose: 25mg po confirmation
o Narcan Challenge Test
o Usual dosage: 50 mg po qd
o Alternate: 100mg Mondays, Wednesdays
o 150 mg Fridays (works for tmt visits)
o Side effects:
§ N/V, abdominal pain, difficulty sleeping, anxiety, nervousness, low energy, HA, joint/muscle pain
§ Can cause liver injury
§ LFTs at baseline and periodically
§ Contraindicated in pts with acute liver dz
§ Hold if AST > 3 Xs nl
o Blockade can be overcome by high dose opiate use, causing overdose
o Enhances recovery rates in first 12 weeks for alcoholic pts when regimen combined with formalized tmt
o Mechanism of action unknown; perhaps decrease in cravings
5. _______ maintenance
o Maintenance and detox with methadone (Dolophine) or levo-alpha-acetylmethadol (LAAM)
o Specialized tmt approaches for ______ dependence
o Legally available only thru federally licensed programs
6. Buprenorphine
o Buprenorphine (Buprenex) (Suboxone): also for tmt of opioid dependence
o Partial u receptor agonist and antagonist (semi-synthetic opioid) > 2 mg
o IV buprenorphine is used for analgesia; patch for chronic pain
o Has a high infinity for the u receptor and will displace morphine or methadone and might cause a withdrawal
o FDA approved sublingual form for detox and maintenance
7. Suboxone
o Suboxone (given SL) is buprenorphine with naloxone and used for opiate dependence
o Naloxone was added to decrease its abuse potential
o Will precipitate withdrawal if crushed and snorted or injected
disulfuram etoh antabuse heart dz naltrexone opioid cravings methadone opioid
withdrawal of alc
- _____ 1 tab daily
- __ complex vitamins & thiamine: 100mg IM qd X 3
- ______ :2 Magnesium Plus tablets TID or mag sulfate 1 g IM q 6h X 4d if hx of withdrawal seizures, high risk for stage 2 withdrawal, or has initial serum magnesium level < 1.5 mEq/L
- _____: hydroxyzine (Atarax, Vistaril) 50 mg IM q 4hr prn Nausea
- Seizure tmt: _____ (Valium) and _____ M(Tegretol) are drugs of choice; Hx of withdrawal seizures: loading dose of carbamazepine, 100 mg qh X 4, then 200 mg q 6h X 7d
multivitamins B magnesium antiemetics diazepam carbamezapine
Tmt: cocaine withdrawal
- ______
- Good nutrition, rest, drug-free environment
- Educate pts as to what they can expect in withdrawal
- Develop plan for recovery
- No pharmacotherapy
- Major complication: ____ ideation
- After a couple of days post withdrawal, ideation quickly dissipates
- If depression is hanging on, use antidepressant: avoid ____ , and ____ (because of serious overdose potential)
- Recommend ____: sertraline (Zoloft) paroxetine (Paxil) and fluoxetine (Prozac)
supportive
suicidal
MAOs, TCA
SSRIs
intoxication w hallucinogens
- -> Treatment:
1. _____ measures
2. Stay with pt. in a quiet room, reassure, ongoing reorientation
3. Might have to sedate with ______ , 1-2 mg po, IM or IV q1-2h (max:10mg)
4. Psychotic sxs: Haldol
supportive
lorazepam
intellectual ability
Treatment
1. Involves ________ approach!
o Social services, therapists as needed, medical team, specialized teachers etc.!
multidisciplinary
tic disorder/tourette’s
TREATMENT
- Because tic symptoms often do not cause impairment, the majority of people with TS require no medication for tic suppression
- However, effective medications are available for those whose symptoms interfere with functioning
- _______ are the most consistently useful medications for tic suppression; a number are available but some are more effective than others (for example, haloperidol and pimozide). (____ and Orap)
- Supportive psychotherapy
neuroleptics
haldol
ADHD TREATMENT - Medical treatment for inattention and hyperactivity - Stimulants: o Methylphenidate (\_\_\_\_) o Dextroamphetamine (\_\_\_\_\_ and Adderall) o Methamphetamine (Desoxyn) o Pemoline (Cyclert)
Ritalin
Dexedrine
MOA of narcan, indications
Naloxone is a specific ______ that can rapidly reverse signs of _____ intoxication. Although it is structurally related to the opioids, it has no agonist effects of its own. If no intravenous access is available, administer naloxone 4 mg intranasally, otherwise administer 0.2–2 mg intravenously and repeat as needed to awaken the patient and maintain airway protective reflexes and spontaneous breathing. Very large doses (10–20 mg) may be required for patients intoxicated by some opioids (eg, codeine, fentanyl derivatives). Caution: The duration of effect of naloxone is only about 2–3 hours; repeated doses may be necessary for patients intoxicated by long-acting drugs such as methadone. Continuous observation for at least 3 hours after the last naloxone dose is mandatory.
opioid antagonist
narcotic
PARANOID PD
TREATMENT
- Disorder causes chronic, lifelong problems
o Patients often do not seek treatment
- _______ (individual) is treatment of choice
- Short term _______ can be used if active psychosis is present (not schizophrenia, brief period where psychosis symptoms present)
psychotherapy
antipsychotics
Schizoid PD
TREATMENT:
- These patients are generally treatment _____
o They lack insight needed for individual therapy, and are mistrustful of group therapy or programs (they don’t want to be around people, why would they go to therapy)
- Treat any co-morbid conditions (anxiety, MDD)
resistant
schizotypal
TREATMENT:
- Use ______ for frank psychosis
- _______ for those individuals who will participate
antipsychotics
psychotherapy
histrionic
- _______ treatment of choice
- Treat underlying depression/anxiety
psychotherapy
narcissistic
TREATMENT
- Generally, do not seek treatment, may be VERY resistant
- _______ treatment of choice
- Treat underlying depression
psychotherapy
antisocial PD
TREATMENT
- Generally ______
- Caution with medications that have abuse potential
ineffective
borderline PD
TREATMENT
- Generally attempt treatment as patients have increased risk of suicide (~10%)
- ______ (Dialectical Behavior Therapy) involves CBT, mindfulness, group therapy
- Meds to treat any frank psychosis
psychotherapy
