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PHAR 358 > Stimulant Use Disorder > Flashcards

Stimulant Use Disorder Flashcards

1
Q

Define stimulant use disorder

A

Inappropriate use of stimulants leading to clinically significant impairment/distress

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2
Q

What are the 3 diagnostic categories of StUD?

A
  1. Problems with use
  2. Problems with lifestyle
  3. Problems with physiology
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3
Q

When diagnosing StUD ≥_ criteria are needed to meet the definition of StUD

A

≥2

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4
Q

StUD Diagnostic Criteria
What falls under ‘problems with use’ (3)

A
  1. Using more (larger amounts/longer)
  2. Much time spent using
  3. Repeated attempts to quit/control use
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5
Q

StUD Diagnostic Criteria
What falls under ‘problems with lifestyle’ (5)

A
  1. Physical/psychological problems related to use
  2. Social/interpersonal problems related to use
  3. Activities given up due to use
  4. Neglected major roles due to use
  5. Hazardous use
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6
Q

StUD Diagnostic Criteria
What falls under ‘physiology’ (3)

A
  1. Craving
  2. Tolerance
  3. Withdrawal
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7
Q

In general, what are stimulants? (3)

A
  1. Most stimulants are derivatives of amphetamine
  2. Referred to as sympathomimetics because they mimic
    physiological effects of epinephrine
  3. Stimulants ↑ motivation, concentration, mood, energy, and wakefulness
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8
Q

What are stimulants that would be categorized as weak? (2)

A
  1. Caffeine
  2. Nicotine
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9
Q

What are stimulants that would be categorized as mild?

A

OTC drugs like cough and cold preparations or diet pills

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10
Q

What are stimulants that would be categorized as moderate?

A

Prescription level stimulants (ADHD or narcolepsy meds)

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11
Q

What are stimulants that would be categorized as strong?

A

Illicit drugs (cocaine and methamphetamine for example)

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12
Q

What are the mechanisms of action of basically all stimulants? (3)

A
  1. Increase CNS and ANS activity
    - Adrenergic overdrive
  2. All effect the reward pathway by increasing DA concentrations at the synapse
    - Cocaine prevents re-uptake only of DA, 5-HT, NE
    - Amphetamines cause release of NT (DA, 5-HT, NE) from storage sites and to various degrees also inhibit re-uptake
  3. Regardless of mechanism, outcome is similar although intensity varies
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13
Q

What are the effects of stimulants on the CNS? (7)

A
  1. Intense euphoria
  2. Increased alertness
  3. Increased concentration
  4. Increased talkativeness
  5. Decreased fatigue (mask signs)
  6. Decreased appetite
  7. Increased sexual behaviour
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14
Q

What are the adverse effects of stimulants? (5)

A
  1. Nausea
  2. Tremors
  3. Tics/twitches
  4. Anxiety
  5. Agitation
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15
Q

What are the effects of stimulants on the autonomic nervous system? (6)

A
  1. Increased body temp
  2. Increased heart rate
  3. Increased blood pressure
  4. Increased respiratory rate
  5. Increased constriction of blood vessels
  6. Dilated pupils
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16
Q

What can stimulant overdoses lead to? (6)

A
  1. Seizures
  2. Coma
  3. Cardiac toxicity (arrhythmia, MI)
  4. Respiratory arrest
  5. Brain hemorrhage
  6. Death
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17
Q

What are the immediate complications of stimulants? (5)

A
  1. Increased risk of violence or illegal behaviours
  2. Increased engagement in risky sexual behaviour and HIV
  3. Psychosis: paranoia, visual and tactile hallucinations
  4. Irritability, anxiety
  5. Pregnancy; poor outcome for fetus
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18
Q

What are some long term complications of stimulant use? (7)

A
  1. Dental decay
  2. Weight loss
  3. Picking at skin with scabs
  4. Panic attacks
  5. Brain changes
  6. Memory loss
  7. Chronic psychotic disorders (secondary to repeated use or unmasking of primary disorder??)
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19
Q

What are the 3 types/phases of StUD management?

A
  1. Acute intoxication
  2. Acute withdrawal
  3. Long term pharmacological management (withdrawal and cravings)
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20
Q

Acute stimulant intoxication or overdose can present with the following symptoms: (9)

A
  1. Mania
  2. Psychosis**
  3. Paranoia
  4. Severe delirium
  5. Increased blood pressure
  6. Chest pain
  7. Agitation
  8. Sweating
  9. Skin-picking
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21
Q

What are the principles of stimulant intoxication management? (3)

A
  1. Generally do not require treatment in an inpatient setting as withdrawal symptoms are not severe or medically complex
  2. Mostly supportive unless delusions or autonomic hyperactivity
  3. Pharmacological agents only if overtly psychotic and agitated or medical crisis
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22
Q

How might agitation be treated in a patient intoxicated on a stimulant? (2)

A
  1. Lorazepam 2-4mg IM or po PRN (q 30min to 6h)
  2. Incomplete response: may add low dose antipsychotic
23
Q

How might psychotic symptoms be treated in a patient intoxicated on a stimulant? (2)

A
  1. Low dose antipsychotic such as risperidone 0.5-2mg/d, olanzapine 2.5-7.5mg/d
  2. Delusions often self-remitting without treatment
24
Q

How might cardiovascular complications be treated in a patient intoxicated on a stimulant? (2)

A
  1. Arrhythmia: administer anti-arrhythmic agents
  2. Tachycardia (+/- hypertension): administer β-blockers (especially labetalol/carvedilol), clonidine
25
Q

How might seizures be treated in a patient intoxicated on a stimulant? (2)

A
  1. Anti-seizure meds if seizing (i.e. diazepam IV, midazolam IM)
  2. No role as a prophylaxis
26
Q

When does stage 1 (crash) of stimulant withdrawal occur?

A

Begins within hours and lasts 4-7 days

27
Q

What are the signs and symptoms of stage 1 stimulant withdrawal? (5)

A
  1. Agitation
  2. Marked dysphoria
  3. Fatigue
  4. Hypersomnolence
  5. Hyperphagia or anorexia
28
Q

When does stage 2 of stimulant withdrawal occur?

A

Begins after the first week and can last up to 10 weeks

29
Q

What are the signs and symptoms of stage 2 stimulant withdrawal, specifically the first week? (4)

A
  1. Normal sleep
  2. Euthymia
  3. Little anxiety
  4. Minimal craving
    (Basically, it’s chill until subsequent weeks on another card)
30
Q

What are the signs and symptoms of stage 2 stimulant withdrawal, specifically the subsequent weeks after the first week? (4)

A
  1. Anhedonia
  2. Increased anxiety and depression
  3. Fatigue
  4. Extreme craving
31
Q

What are the treatment principles of stimulant withdrawal management? (3)

A
  1. Primarily supportive; rarely life-threatening
  2. Non-pharm, including planning for: addictions counselling support, community supports, rehab options, housing needs
  3. Post-acute hyperarousal/anxiety
    - Continue benzos a little longer
    - Mirtazapine (mixed results)
32
Q

What are the goals of therapy for long term pharmacological management of StUD? (4)

A
  1. Achieve abstinence
  2. Maintain abstinence (treat ongoing withdrawal, craving, addiction)
  3. Treat comorbid conditions
  4. Prevent harm to patient and others
33
Q

Sustained neurophysiological changes from stimulant use can lead to: (4)

A
  1. Depressed mood
  2. Loss of pleasure (anhedonia)
  3. Cognitive impairment
  4. Poor health
34
Q

The biggest factor leading to stimulant relapse and challenge to manage is _______

A

craving

35
Q

What is contingency management?

A

If person is engaged working with counsellor/physician, they set up a contract. If every week you check in and your urine drug screen is negative for stimulants, you’ll get a gift card.
- Underlying desire for stimulant users is that feeling of reward, so this is trying to replace that

36
Q

In terms of evidence, what non-pharm methods are good for treating StUD, that is, for abstinence, reduced use, treatment retention? (2)

A
  1. Contingency management
  2. CBT
37
Q

In terms of evidence, what pharmacological methods are good for treating StUD, that is, for abstinence, reduced use, treatment retention? (2)

A
  1. Bupropion (abstinence in moderate, non-daily users)
  2. Mirtazapine (reduce use in MSM)
38
Q

What is the rationale behind using antidepressants to help with withdrawal in StUD?

A

5-HT may attenuate reinforcing effects of amphetamine, and 5-HT/NE counter withdrawal symptoms as depression

39
Q

With all studied antidepressants, what was concluded when it came to using them for stimulant abstinence and mood?

A

Mostly ineffective with regard to abstinence. May have positive mood-related results

40
Q

What is the rationale for using antipsychotics in StUD?

A

Counterbalance excess DA activity and restore NT pathways
- Risk promote craving??

41
Q

Antipsychotics in StUD have consistently shown what?

A

No difference in any treatment outcomes (treatment retention, abstinence, reduced use)

42
Q

If using an antipsychotic for StUD, what should you do? (2)

A
  • Use according to psychosis guidelines if indicated; review need after 6 months
  • Avoid aripiprazole; risp > arip
43
Q

What is the rationale behind using prescribed stimulants in treating StUD?

A

Substitution/replacement therapy with something less bad

44
Q

What are the study results for actually using prescribed stimulants in treating StUD? (2)

A
  1. Mixed results for long-term benefit, possible reduction in use or cravings (esp if not actively using at baseline). Usually no different in treatment outcomes observed
  2. Not generally recommended
    - Risks: worsening pyschosis, mood lability
    - If used, establish target outcomes and monitor regularly for risk vs. benefit
45
Q

What is the rationale behind using dopamine agonists to treat StUD?

A

Chronic stimulant use leads to DA depletion

46
Q

What are the dopamine agonists that have been tested in StUD? (2) What were the results?

A
  1. Amantadine 200-400mg/day
  2. Bromocriptine 2.5mg po TID
    General results not promising. Some possible benefit in severe withdrawal
47
Q

What is the current indication for modafinil?

A

Narcolepsy

48
Q

What is the rationale behind using modafanil in StUD treatment? (3)

A
  1. Differs from amphetamines: increases NE, histamine, and glutamate, and decreases GABA
  2. Has been shown to blunt cocaine euphoria
  3. No added adverse effects when combined with cocaine (HR, BP, T)
49
Q

What are the study results of using modafanil in StUD treatment?

A

Mixed evidence of benefit: possibly useful to reduce cocaine use, but 2 neg trials and risk of increased effect of concurrent stimulant use

50
Q

What were the study results of using buproprion + naltrexone ER for StUD treatment?

A

There was statistically significant difference between groups, but lowe response rates for all participants anyways

51
Q

In summary, what are the long-term management strats for StUD? (2)

A
  1. Non-pharm options
    - Psychosocial referrals
  2. Pharmacological treatment
    - Risperidone 2mg po HS
52
Q

What is the pharmacist’s role in medication management in StUD patient? (2)

A
  1. Eliminate unnecessary/non-beneficial meds
    - Antipsychotics
    - Antidepressants
  2. Eliminate harmful meds
    - Benzos long-term
    - Stimulants
53
Q

Bottom line of StUD treatment is that there is no…

A

No established pharmacotherapy for StUD

PHAR 358 (12 decks)

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