Substance Abuse Flashcards

Question

Naltrexone- Rivia®- indications

Answer 1

Narcotic abuse | Alcohol dependence

Answer 2

Competitive mu (µ) opioid receptor antagonist Naltrexone blocks ß- endorphin which stimulates dopamine release Naltrexone blocks ethanol- induced DA release in NAC >> May attenuate rewarding effects of alcohol

Answer 3

Moderate effects at best More recent study in VA population found naltrexone no different than placebo on time to relapse, % of drinking, or # of drinks per drinking day Long-term effectiveness??? One study has shown beneficial effects diminish gradually over time Long-acting injectable: one study has shown effects sustained during 6 months of treatment

Answer 4

Approved to maintain abstinence after detoxification

Answer 5

Unknown “restores balance” between glutamate and GABA May ↓ glutamate overactivity Binding to allosteric polyamine site on NMDA R and ↓ polyamine modulation of NMDA activity Binding postsynaptic metabotropic glutamate receptors (mGluR5) and alter NMDA Receptor number and function Binding to presynaptic mGluR5 and ↓ glutamate release May ↓ ability of ethanol to activate mesolimbic dopamine system

Answer 6

Moderate effects at best Similar decreases in drinking frequency, and similar relapse rates as naltrexone 13 trials, mostly European

Answer 7

In long-term trials, 16-30% of subjects completely abstinent at 48 and 52 week endpoints

Answer 8

Only ADR reported in > 10% patients and at a rate > placebo was transient diarrhea Asthenia (6%) Anxiety (6%) Insomnia (7%)

Answer 9

Renally eliminated | Should not be used if CCI < 30 dl/ml

Answer 10

``` Tremor GI (nausea/vomiting) Mild diaphoresis Vital signs increase (mild) Sleep disturbance Hallucinations Seizures (7%) ```

Answer 11

``` Incidence: >/= 1 sign/symptom 95% Time Course: Onset: 8-12 Hours Peak: 24-36 Hours Duration: 60-72 hours(important!) ```

Answer 12

``` Delirium Delirium Tremems (DT’s) Hallucinations Agitation Tremors Vital signs increased (Marked) Diaphoresis (marked) Sleep disturbance ```

Answer 13

``` Incidence: 5% Time Course: Onset: 48-60 hours Peak: 72 hours Duration: 120-168 hours (Important!) ```

Answer 14

``` Prevent withdrawal symptoms including Seizures Delirium Tremens Medical and psychological complications Encourage long-term abstinence Encourage/refer to outpatient treatment (AA, 12 step programs, etc.) ```

Answer 15

Benzodiazepine

Answer 16

Mild: less than 8 on CIWA no pharmacological therapy Moderate: 8-15 Use medication Severe: 15 Use medication (enough to control symptoms) and monitor closely

Answer 17

Monitoring patient every 4-8 h CIWA-Ar until score has been < than 8for 24 h Use additional assessments as needed

Answer 18

Administer 1 of the following medications every hour when CIWA-Ar is ≥ to 8 Chlordiazepoxide 50-100 mg Diazepam 10-20 mg Lorazepam 2-4 mg Repeat CIWA-Ar 1 after every dose to assess need to further medication

Answer 19

Long acting

Answer 20

Preferred: Long-acting Chlordiazepoxide (Librium) Diazepam (Valium)

Answer 21

Severe liver disease: Short-acting Lorazepam (Ativan)- used frequently Oxazepam (Serax)

Answer 22

Complicated withdrawal Patient NPO/vomiting Parenteral BZD Chlordiazepoxide 50mg PO = lorazepam 2-4mg IM Supplement with lorazepam 2-4mg IM q1h for breakthrough signs/symptoms

Answer 23

``` Benzodiazepines drug of choice IV diazepam 5-10mg may repeat q 5min till termination seizure IM lorazepam 4mg Correction of Electrolyte Imbalances IV magnesium 1g q hours for 1st day IV thiamine (as in intoxication) ```

Answer 24

IV Benzos ‘till light somnolence is achieved Haloperidol- given only for severe agitation unresponsive to benzos IV thiamine

Answer 25

``` Simple taper 25% dose reduction per week until 50% of original dose is reached Then decrease dose by 1/8 every 4-7 days If therapy > 8 weeks 2-3 week taper is recommended If therapy > 6 months 4-8 week taper should be used If therapy > 1 year Strong consideration should be given to using long-acting agents (Diazepam, Clonazepam) ```

Answer 26

Rebound anxiety Recurrence or relapse of symptoms Withdrawal symptoms Onset Short-acting agents ~ 1-2 days Longer-acting agents ~ 2-4 days

Answer 27

``` Anxiety Insomnia Restlessness Muscle tension irritability ```

Answer 28

Seizures Hallucinations Paranoid delusions Confusion Less frequently- nausea, malaise, blurred vision, diaphoresis, nightmares, ataxia, hyperreflexia

Answer 29

Short-acting agents ~3 days after discontinuation Longer-lasting agent ~1 week after discontinuation

Answer 30

High BDZ doses Long duration of therapy Concurrent meds/drugs that lower seizure threshold

Answer 31

``` Restlessness/anxiety Euphoria Grandiosity Hypervigilance Tachycardia/elevated blood pressure Mydriasis Sweating and/or chills Nausea, vomiting, diarrhea Psychosis Cardiovascular collapse death ```

Answer 32

- Dilated pupils (high dose) - Dry mouth - Bad breath - Frequent lip licking - Decreased appetite and sleep - Irritable, argumentative - Talkative but tangential - Runny/bloody nose - Paraphenalia

Answer 33

Treat and monitor medical problems Hyperthermia, Hypertension, Cardiac arrhythmias, Stroke Psychiatric Problems Benzodiazepines for anxiety History and drug screen 1st because often used in combo with ethanol, opioids so benzos can increase sedation and respiratory depression

Answer 34

Dependence Therapy, groups, etc 12 step program No proven pharmacotherapy, Disulfiram shows some promise with cocaine

Answer 35

For severe symptoms in first 24 hours benzodiazepines or antipsychotics might be helpful for delusions, paranoia, compulsive behavior

Answer 36

Seizures Hyperthermia Ischemic chest pain Suicide

Answer 37

``` Euphoria Dysphoria Apathy Motor retardation Sedation Attention impairment Miosis ```

Answer 38

``` Lacrimation Rhinorrhea Mydriasis Piloerection Diarrhea Yawning Insomnia Muscle aching ```

Answer 39

Reverse intoxication with naloxone 0.4-2mg IV q 2-3 min up to 10mg Secure airway

Answer 40

Opioid agonists | Opioid antagonists

Answer 41

``` Opioids inhibit cyclic AMP system Chronic use discontinuation Leads to cyclic AMP in the adrenergic neurons becomes overactive Noradrenergic brain activity increases Contributes to withdrawal symptoms Adrenergic autoreceptors When stimulated decrease neural activity ```

Answer 42

``` Yawning Lacrimation Rhinorrhea Perspiration Restlessness Insomnia ```

Answer 43

``` Tremors Dilated Pupils Goosebumps Anorexia Muscle Twitching Myalgia/arthralgia Abdominal pain ```

Answer 44

``` Nausea Extreme Restlessness Vital Signs ↑ Tachycardia Hypertension Fever Hot/Cold Flashes ```

Answer 45

``` Vomiting Diarrhea Weight loss Dehydration Hypotension ```

Answer 46

With a medical complication (still great discomfort, incapacitating)

Answer 47

Alpha adrenergic autoreceptors

Answer 48

Heroin: 10 day treatment Methadone: 14 day treatment Clonidine taper in both cases

Answer 49

Vital signs before each dose | Titration: ↑ 5-10mg QOD as tolerated

Answer 50

Mechanism of action µ and ō opioid withdrawal agonist Suppresses opioid withdrawal symptoms Blocks effect of other opioids Use for detox limited to a licensed treatment facility

Answer 51

Constipation, sweating, urinary retention | Respiratory depression in intolerant individuals

Answer 52

µ receptor partial agonist and weak K receptor antagonist Similar effects as methadone Opioid antagonist at higher doses Controls cravings Still some sense of euphoria Safer than heroin Not as addictive, little risk of overdose

Answer 53

Should not be initiated until patient is opioid free for 7-10d Poor compliance and high drop-out rates limit usefulness

Answer 54

DA, NE, 5-HT, glutamate, GABA, and endogenous opioid peptides Activates nicotinic acetylcholine receptors in the brain

Answer 55

``` Patch Gum Lozenge Nasal Spray Inhaler ```

Answer 56

Buproprion Varenicline Clonidine TCA’s

Answer 57

In refractory smokers

Answer 58

Blocks reuptake of DA and NE Acts as a noncompetitive antagonist on nAch receptor Reduces nicotine reinforcement, withdrawal, and craving

Answer 59

agonizes and blocks nicotinic acetylcholine receptors

Answer 60

Black Box Warning Neuropsychiatric Symptoms and Suicidality Weigh varenicline risks vs. benefits of smoking cessation

Answer 61

Clonidine Modest efficacy in smoking cessation trials ``` TCA’s Nortriptyline (inhibit reuptake NE and 5-HT) Significant disadvantages Anticholinergic burden Cardiac side effects ```