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Thera II > Substance abuse > Flashcards

Substance abuse Flashcards

1
Q

What are the complications of opioid use disorders

A

overdose
increase risk of certain cancers (mouth, throat, liver, colon, breast)
infections (aspiration, pneumonia, cellulitis, TB, Hep C/B, HIV)
Complications of injection (vasculitis, emboli)
Psych comorbidity (depression, anxiety)
suicide
trauma
sexual dysfunction
poor nutrition
severe constipation
insomnia, sleep apnea

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2
Q

Best practices before prescribing OUD

A

-before prescribing, assess risk of developing OUD and interpret urine drug test
-in collaboration with pt, determine goal of therapy
-ensure services are culturally, trauma and gender informed
-aim for dose <90 MEQ of morphine (>50 should have noloxone kit)
sign treatment agreement outlining expectation of the pt on opioid therapy
-avoid prescribing large quantities at any time
-monitor pt frequently for efficacy and safety as well as double docturing and aberrant mediation taking behavior (running out early, urine drug test negative for substance ordered)
-if aberrant behaviors, should have more intensive monitoring to decrease risk (dispense weekly or twice weekly),
-increase frequency of urine drug test if unexpected results occur
-if it does not result in change, evaluate SUD and treat accordingly

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3
Q

non pharm approaches for OUD

A

-nonjudgmental appraoch
-consider stages of changes to assess pt readiness
(Precomtemplation, contemplation, preparation, action, maintenance, relapse)
-psychosocial interventions (CBT, contingency management, counselling, trauma therapy, psychoeducation, motivational enhancement therapy, interpersonal therapy, network support)

**combo of CBT + motivational enhancement therapy demonstrated a significant increase in abstinence **

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4
Q

Pharm approaches for acute withdrawal of OUD

A

Methadone or Buprenorphine (lower dose 5-10% Q2-4 weeks)
+
Clonidine 0.1-0.2 mg Q6=8h PRN x 5-7 days
-best used as adjunct therapy during tapering

If they are having moderate to severe OUD-> best to use OAT as maintenance treatment rather than withdrawal treatment

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5
Q

What are pharm approaches to maintenance treatment for OUD

A

Integration of nonpharm + pharm = best practice

Moderate to severe OUD:
First line
Buprenorphine/ Naloxone (Suboxone) 8-24mg/day
-they also have an extended release monthly SC injection (for those who can’t adhere to daily dosing)
*Requires >12-24 hours of opioid free prior to starting

Second line
Methadone 60-120 mg daily
can start immediately

Third line/ Adjunct
Slow release morphine
-used as adjunct during methadone initaiton or stand alone for those who failed methadone or buprenorphine

Duration: 12 months **
-if there is a high relapse rate within 1 year; may need longer treatment

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6
Q

If your patient with OUD has a concurrent mental health problem, should you treat at the same time? first? or wait till after

A

Should be treated in tandem with OUD

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7
Q

Side effects of methadone

A

Methadone mnemonic

M- Wt gain
E-erectile dysfunction
T-QTc prolongation
H-hypotension
A-
D-dizziness, diaphoresis
O-
N- N/V
E- sEdation

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8
Q

Side effects of suboxone

A

Danic

Diaphoresis
A-abdominal pain
N- n/v
I- insomnia
C- constipation

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9
Q

S/S of opioid withdrawal?

A

Flappy hands

F-fever
L- Lacrimation
A- anxiety
P-pupillary dilation
P-piloererection
Y- yawning

H-rHinorrhea
A- aches (muscles)
N- nausea / vomiting
3D- diarrhea / dysphoric mood/ diaphoresis
S- insomnia

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10
Q

opioid toxicity s/s

A

resp depression (shallow breathing, resps <12
constricted pupils
pale/cold skin
blue fingernails
being unresponsive

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11
Q

treatment for opioid toxicity

A

CPR + Naloxone
1 spray (4mg/spray) intranasally, repeat dose @2-3 min in alternate nostril PRN if no response. (if 5 doses and no response-likely not OD)
or
0.4 mg IM x1, repeat dose Q5min PRN

Naloxone duration is 20-90 min, opioids duration much longer -> should monitor for at least 4-6 hours after last naloxone dose

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12
Q

management of OUD in pregnancy

A

Maintenance therapy is #1 (methadone or buprenorphine)
-> detox carries increase risk spontaneous abortion

SC version is not safe in pregnancy

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13
Q

management of OUD in breastfeeding

A

use of methadone in BF may help NAS in infant
-any dose >100 mg/ day can increase babe sedation and resp depression

**recommend breastfeeding regardless unless HIV +

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14
Q

S/S NAS in babes

A

high pitch cry
rigidity
fever
sneezing/ congestion
muscle tension (hypertonia)
insomnia
tremors
hyperreflexia
vomiting
diarrhea
feeding problems
sweating
yawning
tachypnea

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15
Q

Management of NAS

A

Nonpharm #1
Feed
Console
Rock
Cuddle
Rooming in
Pacifier use
frequent small feeds with hypercaloric formula
frequent diaper changes with barrier ointment
quiet environment, low light, white noise

If Moderate to severe NAS -> pharm (opioid therapy)

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16
Q

What are the alcohol withdrawal questionnaire

A

CIWA-Ar (best)

17
Q

complications of alcohol use disorder

A

poor nutrition
liver disease
bleeding
tremor, ataxia, seizure, wernicke encephalopathy
antonomic dysfunction
neuropathy
trauma
increase risk of certain cancers
infections
concurrent psych disorder
psychosis
insomnia

18
Q

What is best treatment approach for AUD

A

nonpharm + pharm

19
Q

what are nonpharm approaches to AUD

A

nonjudgmental approach
-consider stages of change and assess readiness for pt
(precomtemplation, comtemplation, preparation, action, maintenance, relapse)
-motivational interviewing = good efficacy
-psychosocial tx options:
-psychoed, relapse prevention training, trauma therapy, CBT, motivational enhancement therapy, interpersonal therapy, network support (AA, etc)

Treat anxiety+ depression comorbidity simultaneously

20
Q

Which vitamin should be added to all AUD patients

A

First line (ALL)
Thiamine 200mg OD (increased risk of Wernicke encephalopathy)

21
Q

What are pharm approaches for acute alcohol withdrawal

A

most can be managed with supportive measures and monitoring

if severe (based on CIWA score >10 )
-> BENZO
#1
Ativan 1-2 mg Q2-4h PO until CIWA score <8 on 2 consecutive readings 1 hour apart
or
Diazepam 20 mg Q1-2h Po until CIWA socre <8 on 2 consecutive readings 1 hour apart

22
Q

Pharm approaches for AUD if wishes to abstain completely and if they wish to still use

A

First line
NALTREXONE 50 mg PO OD
-treatment of choice if goal is NOT ABSTINENCE
CI= opioid therapy/ you must be >7 days opioid free prior to starting this

ACAMPROSATE 666 mg PO TID
-treatment of choice if goal is ABSTINENCE
use if hepatic insufficiency b/c this med is renally excreted
-if using opioids, use this med instead

MUST BE >4 days of alcohol abstinence to start
-similar idea to suboxone

23
Q

AE of naltrexone

A

Think GI
abdominal cramps, pain, nausea

24
Q

AE of acamprosate

A

Think cramp = n/v/d

PROSATE

P-Pruritus
R-rash
O-oh no diarrhea
S- suicidality
A-abdominal pain
T - nausea and vomiting
E

25
Q

second line treatment options for AUD

A

Anticonvulsants (topiramate or gabapentin)

26
Q

management of AUD withdrawal in pregnancy

A

drinking and pregnancy = FASD
** withdrawal should take place in medially supervised setting where loading dose of benzo can be administered**

27
Q

Pharm management of AUD in pregnancy

A

Acamprosate and naltrexone not studied in pregnancy (benefit must outweigh the risks)

28
Q

management of AUD in breastfeeding

A

Acamprosate and naltrexone not studied in pregnancy (benefit must outweigh the risks)

29
Q

Elderly tend to have more severe withdrawal than young pt, what is the management of AUD and withdrawal in elderly

A

1 Lorazepam (withdrawal)

-> could benefit from relapse prevention meds.

30
Q

S/S of alcohol withdrawal

A

“TINA”

T-tremors
I- insomnia
N- nausea / vomiting
A-anxiety

insomnia
n/v
anxiety
hand tremor
transient visual, tactile, auditory hallucinations or illusions
generalized tonic clonic seizures
sweating, pulse >100

31
Q

What is the typical guidelines to tapering opioids

A

5-10% Q2-4 weeks
(can be 1-6 months or longer >12-24 months)

32
Q

Indicate 4 labs that you would monitor for while your pt is on an antipsychotic

A

GALE

Fasting glucose
A1C
Fasting lipid panel
Electrolytes
+
ECG

33
Q

High rates of substance abuse with schizophrenia patients. what are nonpharm interventions ?

A

encourage smoking cessation (toxins in cigarettes can interact with antipsychotics and smokers may need higher doses of antipsychotics leading to increase a/e)

Harm reduction approach is key
Motivational interviewing
Referral to MH programs that provide comprehensive integrated approaches

34
Q

nonpharm interventions for cocaine abuse

A

Cornersone of treatment is psychosocial, behavioral interventions

address concomitant MH concerns
identify and avoid triggers
initiate healthy lifestyle choices
distraction techniques to deal with cravings
referral for MH and addiction services
CBT
motivational interviewing

35
Q

cocaine pharm internventions

A

there are none officially indicated

psychostimulants (methylphenidate or dextroamphetamines)
or
nonstimulant (atomextine or clonidine)

Antipsychotics -> mixed results

Antidepressant ->not effective

Antiseizures (can help increase abstinence and decrease cravings)
Topiramate 50mg/day

**assess and treat concomittant depression/anxiety
note: bupropion, fluoxetine and trazodone and some TCA can falsely test + for amphetamine in urine drug screen

36
Q

relational skills in motivational interviewing?

A

pt centered
avoids threats to pt competency and autonomy (“what do you think of this” rather than point out)
pt sense making and practical reasoning

37
Q

Steps to Motivational interviewin

A

RRTS
Rapport
Reframe
Tailored interventions
STEPS next

1.Develop rapport
2. reframe problem “you are hesitant to stop med b/c your stomach will hurt”/ verbalizing ambivalence is a power tool in MI.
3. provide tailored info to address concerns
4. plan next steps (before offering suggestions ask if attempted this change first, support pt self efficacy by providing encouragement)

Thera II (12 decks)

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