Substance Abuse

Question 1

How do opioids cause euphoria

Answer 1

they activate the brain reward pathway in which dopamine is stimulated in the mesocorticolimbic system (VTA and NA to prefrontal cortex, amygdala, and olfactory tubercle)
Other NTs may be involved but DA is most common

Question 2

Ethanol MOA

Answer 2

multiple NT pathways
may activate DA system indirectly by facilitating GABA neuron activity in pars reticulate, which disinhibits the VTA, DA neurons and increases DA in the NA
May also be some interaction between serotonin and ethanol reinforcement

Question 3

Signs and Symptoms of ethanol toxicity

Answer 3

mood lability
inappropriate aggressive or sexual behavior
giddiness or verbally loud
impaired judgment
somnolence and coma as blood levels increase

Question 4

Lethal ethanol concentrations

Answer 4

0. 02-0.09 = prolonged reaction time, muscular incoordination
1. 1-0.2 = obvious prolonged reaction time and incoordination, ataxia, mental impairment
2. 2-0.3 = marked ataxia, some dysarthria, possible N/V
3. 3-0.4 = severe dysarthria, amnesia, hypothermia
4. 4-0.6 = alcoholic coma, decreased respiration, decreased blood pressure, and decreased body temperature
5. 6-0.8 = fatal! pt goes into respiratory arrest, aspiration of GI contents, airway obstruction due to flacid tongue

Question 5

Medications available to reverse the effects of alcohol

Answer 5

none fully reverse effects
caffeine and stimulants may induce arousal and alertness
flumazenil can reverse BDZ effects at GABA receptors

Question 6

Behavioral symptoms of opioid intoxication

Answer 6

euphoria and sedation are most common
analgesia
slurred speech
impaired memory
impaired attention
psychomotor retardation

Question 7

Physiological symptoms of opioid intoxication

Answer 7

N/V
respiratory depression which may progress to coma
constipation in chronic users
itching
pinpoint pupils
slow HR
low BP

Question 8

Medications available to reverse opioid intoxication

Answer 8

Naloxone

Question 9

Naloxone complications

Answer 9

necessary to readminister to patient, otherwise the patient can go into cardiopulmonary arrest.
can also precipitate withdrawal symptoms in dependency cases

Question 10

Symptoms of uncomplicated alcohol withdrawal

Answer 10

vivid dreams
insomnia
tremor
N/V
tachycardia
hypertension
headache

Question 11

symptoms of complicated alcohol withdrawal

Answer 11

all symptoms of uncomplicated withdrawal
seizures
delirium
hallucinations

Question 12

treatment of uncomplicated alcohol withdrawal

Answer 12

benzodiaxepines (lorazepam, oxazepam, diazepam, and chlordiazepoxide)

Question 13

BDZs used in patients with compromised liver function

Answer 13

lorazepam
oxazepam
eliminated in kidneys only

Question 14

symptoms of opioid withdrawal

Answer 14

N/V/D
deydration
irritability
restlessness
yawning
tremulousness
twitching
increased HR and BP
chills
increased body temp
piloerection
rhinorrhea
lacrimation
dilated pupils

Question 15

Meds used to manage opioid withdrawal

Answer 15

clonidine 0.1-0.2mg q6-8h for shaking, sweating, and piloerection
dicyclomine 20mg q8-12h for abdominal cramps
loperamide 4mg po initially then 2mg po prn for diarrhea (max 4/day)
trimethobenzamide suppository 200mg daily prn N/V and to help with stomach contractions and cramping
NSAIDs/analgesics for general pain
BDZs for anxiety and sleep

Question 16

Buprenorphine Side effects

Answer 16

constipation
sedation
headaches

Question 17

medications approved for alcohol dependance

Answer 17

disulfiram
naltrexone
acamprosate

Question 18

disulfiram mechanism

Answer 18

irreversibly blocks aldehyde dehydrogenase which metabolizes alcohol. precipitates effects of intoxication.
negative reinforcement

Question 19

usual starting dose of disulfiram

Answer 19

250mg/day

Question 20

disulfiram adverse effects

Answer 20

rash
drowsiness
metallic or garlic-like taste
headache

Question 21

disulfiram lab monitoring

Answer 21

liver functions at baseline and periodically. can cause hepatotoxicity. discontinue if lab values are 3x UL, retest q1-2 weeks until lab values are normal again

Question 22

Naltrexone mechanism

Answer 22

competitive opioid antagonist that decreases alcohol intake
more selective for mu-opioid receptors
decreases both craving and euphoria

Question 23

usual therapeutic dose of naltrexone

Answer 23

50mg/day

Question 24

withold naltrexone for ___ days

Answer 24

7-10 days following last use and give only when urine drug screen for opioids is negative

Question 25

naltrexone adverse effects

Answer 25

hepatotoxicity (normally at doses >250mg/day)
nausea
headache
fatigue
nervousness

Question 26

Patients taking naltrexone should carry…

Answer 26

a pocket warning card or wear a warning bracelet

responders will need to know that opioids will not work in this patient at normal doses if an emergency occurs

Question 27

Acamprosate Mechanism

Answer 27

NMDA receptor antagonist
modulate and normalize NMDA receptor system
ineffective in reducing acute withdrawal symptoms
may have some GABA exciting activity

Question 28

therapeutic dose of acamprosate

Answer 28

666mg orally tid (2 333mg tablets)

Question 29

acamprosate adverse effects

Answer 29

nausea
diarrhea
increased rate of suicidal thoughts in patients treated for 1+ years

Question 30

medications used for opioid dependence

Answer 30

methadone and buprenorphine (opioid agonists)

naloxone, naltrexone, nalmefene (opioid antagonists)

Question 31

Where can methadone maintenance be provided?

Answer 31

in an officially designated and approved methadone clinic

Question 32

when are physicians allowed to prescribe buprenorphine

Answer 32

if the physician meets the requirements of expertise in the area of substance
if they receive 8 hours of approved training
registration with the DEA to obtain a specially designated DEA number after receiving a “waiver”