Psychiatry / BH / addiction Flashcards
What is a treatment regimen for outpatient treatment of alcohol withdrawal?
diazepam tablets 10mg - 4-3-2-1 as follows over 4 days:
diazepam 10mg Q6H on day 1, diazepam 10mg Q8H on day 2, diazepam 10mg Q12H on day 3, and diazepam 10mg QD. (4 pills – 3 pills – 2 pills – 1 pill)
gabapentin is alternative
What is criteria for outpatient treatment of alcohol withdrawal?
no hx of severe alcohol w/d (seizures, DTs, MICU stay)
CIWA < 10
no conconcurrent sedative use d/o
Stable home environment
low BAL < 400
ability to call clinic
What is contraindication for naltrexone ?
Naltrexone should be avoided in individuals using opioids or prescribed opioids for pain management, as well as in those with acute hepatitis or hepatic failure; in such patients, the alternative first-line treatment, acamprosate is appropriate.
NNT - 12 to prevent a return to heavy drinking
What is dose of acamprosate, and what is contraindication?
666mg daily - 2 tabs TID
CrCL < 30 - hold med
What might be a treatment for bipolar disorders?
Quetiapine is a reasonable choice that can be used for acute mania, for bipolar disorder with mixed features, and as maintenance therapy. Other medications with high-quality evidence to support their use in bipolar disorder include lithium, valproic acid, lamotrigine, cariprazine, lurasidone, and antipsychotics.
What is difference between bipolar 1 and 2?
Bipolar disorders often present in late childhood or early adolescence. Outcomes can be improved by early recognition. Manic episodes that occur with bipolar I disorder are usually easy to identify. However, patients with bipolar II disorder, such as this patient, may have a hypomanic episode that goes unrecognized, and the patient may present with persistent depression.
what are key questions to ask re: alcohol withdrawal syndrome?
1) severity of last syndrome
2) how many episodes of al w/d
3) severity of current syndrome
4) risk of severe or complicated alcohol withdrawal
What is the Kindling effect in alcohol withdrawal?
repeated alcohol w/d episodes will become progressively worse
even in mild episodes
What is PAWSS for alcohol w/d?
Prediction of severity of alc withdrawal
What are the four options for treating alc withdrawal?
1) symptom driven CIWA benzo
2) fixed dose benzo
3) front-loaded benzo
4) front loaded phenobarb
what are three advantages of diazepam?
1_ fast time to peak
2 long half life
3) multiple formulations
when to consider phenobarb?
hx of complicated w/d
at risk of severe complicated alc withdrawal
actively withdrawing despite high BAL
current severe alc withdrawal
delirium or encephalopathy
benzo non-response
What is the dosing for phenobarb?
10 mg/kg
can give as IM every 3 doses for 3 doses to load
therapeutic range if 10-40mcg/ml in the blood
can multiply dosing by 1.5 to estimate blood level
What is the scale used to assess phenobarb response?
RASS
Richmond Agitation Scale
when is a situation not to use diazepam?
significant hepatic impairment
Which med is a full agonist for OUD? partial?
methadone is full agonist; bupreonorphine is partial
Which med is a full ANTAGONIST
naltrexone
Methadone initiation - what is initial treatment?
get an EKG
option 1: strat 10mg q4hr prn opoiid withdrawal (start with 5mg if medically ill, elderly, or benzos)
option 2: start methadone 30mg po x1 dose, then additional 10mg in >= 4 hrs prn opioid withdrawal
How to use methadone in acute pain situation?
if pt on methadone, consider dividing the dose and administaring every 6-8 hours or give regular dose; do not consider methadone to be adding any considerable pain relief
can also use non-pharma options, non-opioid meds, opioid short acting
How to manage suboxone in acute pain situation?
continue home suboxone dose if 16 or less mg AND then do multi-modal approach using high affinity IV full agonist opioids
if more than 16mg, consider bringing down to 16mg day before surgery or even down to 8mg and use IV paoin meds PRN
oxy 10-15 or higher doses of IV dilaudid
What’s traditional approach to initiating buprenoprhine?
1) calculate COWS
2) once COWS > 12, give bupe/naloxone 4mg SL now - OR - 2 mg SL now and may repeat in 3 min
3) reassess in one hour, if symptoms give additional 4-8 mg SL
4) continue every 4 hours until symptoms resolve, up to 16-24 mg/day
What qualities of current fentanyl supply make it hard to treat?
highly lipophilic
- so when patients are using a lot, it gets stored in the fat tissue and acting as extended release product
What is the microdosing approach to buprenorphine?
repeated microdoses with sufficient overall doses should not precipitate withdrawal
.2»_space; ,2 > ,8 + .2 etc with a full agonist (cross taper)
start with butrans patch and then add a bit of suboone each day
when to use CIWA protocol?
low risk for serios withdrawal
able to communicatie
not delirious
