Psychiatry / BH / addiction

Question 1

What is a treatment regimen for outpatient treatment of alcohol withdrawal?

Answer 1

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

Question 2

What is criteria for outpatient treatment of alcohol withdrawal?

Answer 2

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

Question 3

What is contraindication for naltrexone ?

Answer 3

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

Question 4

What is dose of acamprosate, and what is contraindication?

Answer 4

666mg daily - 2 tabs TID
CrCL < 30 - hold med

Question 5

What might be a treatment for bipolar disorders?

Answer 5

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.

Question 6

What is difference between bipolar 1 and 2?

Answer 6

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.

Question 7

what are key questions to ask re: alcohol withdrawal syndrome?

Answer 7

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

Question 8

What is the Kindling effect in alcohol withdrawal?

Answer 8

repeated alcohol w/d episodes will become progressively worse

even in mild episodes

Question 9

What is PAWSS for alcohol w/d?

Answer 9

Prediction of severity of alc withdrawal

Question 10

What are the four options for treating alc withdrawal?

Answer 10

1) symptom driven CIWA benzo
2) fixed dose benzo
3) front-loaded benzo
4) front loaded phenobarb

Question 11

what are three advantages of diazepam?

Answer 11

1_ fast time to peak
2 long half life
3) multiple formulations

Question 12

when to consider phenobarb?

Answer 12

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

Question 13

What is the dosing for phenobarb?

Answer 13

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

Question 14

What is the scale used to assess phenobarb response?

Answer 14

RASS

Richmond Agitation Scale

Question 15

when is a situation not to use diazepam?

Answer 15

significant hepatic impairment

Question 16

Which med is a full agonist for OUD? partial?

Answer 16

methadone is full agonist; bupreonorphine is partial

Question 17

Which med is a full ANTAGONIST

Answer 17

naltrexone

Question 18

Methadone initiation - what is initial treatment?

Answer 18

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

Question 19

How to use methadone in acute pain situation?

Answer 19

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

Question 20

How to manage suboxone in acute pain situation?

Answer 20

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

Question 21

What’s traditional approach to initiating buprenoprhine?

Answer 21

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

Question 22

What qualities of current fentanyl supply make it hard to treat?

Answer 22

highly lipophilic
- so when patients are using a lot, it gets stored in the fat tissue and acting as extended release product

Question 23

What is the microdosing approach to buprenorphine?

Answer 23

repeated microdoses with sufficient overall doses should not precipitate withdrawal

.2&raquo_space; ,2 > ,8 + .2 etc with a full agonist (cross taper)

start with butrans patch and then add a bit of suboone each day

Question 24

when to use CIWA protocol?

Answer 24

low risk for serios withdrawal

able to communicatie

not delirious

Question 25

what is the pharmacology of alcohol withdrawal?

Answer 25

downregulation of GABA and upregulation of glutaumate