Substance Abuse Disorders - Therapeutics (Dr. Aebi) Flashcards
What are the main points in classifying someone as having substance abuse?
At least 2 of these present in a 12 month period
- Substance often taken more than was intended
- Efforts to cut down unsuccessful
- Lots of time spent obtaining/using/recovering from effects
- Craving
- Continued use despite problems
- Important things given up because of drug
- Continues use despite knowledge that there is a problem
What is the best way to stop using nicotine products?
In a combination of pharmacotherapy and psychosocial interventions (drug and therapy together).
Can you use NRT for smoking reduction? Smoking cessation?
Both
What is first-line therapy for smoking cessation?
Nicotine replacement therapy
Bupropion
Varenicline
What is second-line therapy for smoking cessation?
Nortriptyline
Clonidine
What is the best nicotine replacement therapy?
Whatever the patient is willing to try.
Which NRT agent can cause vivid dreams?
The nicotine patch
What is a serious adverse reaction to NRT?
Tachycardia
Can you cut the patch if the dose seems too big? What if it gives you bad dreams at night?
Cannot cut this patch, nicotine will evaporate. Patch can be worn for 16-24 hours.
What happens if you leave the patch on for more than 24 hours?
Skin irritation
What is the MOA of varenicline?
It is a partial agonist at alpha-4-beta-2 neuronal nicotinic receptors.
What monitoring is needed for varenicline?
Abstinence
Renal function
What is contraindicated with varenicline?
Bupropion
Moderate alcohol use
If a patient has any of the following side effects of varenicline, what should you do? Angina, MI, CVA, depression, mood changes, hostility, suicidal ideation.
It is best to switch drugs
Can you use varenicline for a person being treated for bipolar disorder?
It is best not to… there is a black box warning against possibly worsening psychiatric symptoms.
What is the MOA of bupropion?
It inhibits neuronal uptake of dopamine and NE
What monitoring do you need for bupropion?
Abstinence from tobacco, renal function, BP, psychiatric reactions
What drug should you avoid if you have had bulimia or anorexia?
bupropion
Which drug should you avoid if you are on the antibiotic linezolid?
Both nortiptyline and bupropion
With bupropion, by how much should you separate BID doses?
By at least 8 hours apart. If you miss a dose, skip it and take the next dose as scheduled.
What is the MOA of nortriptyline?
TCA that inhibits serotonin and NE, anti-muscarinic, blocks H1 and alpha1
Where is nortriptyline metabolized?
In the liver by 2D6
Which smoking cessation aide typically causes constipation?
Nortriptyline
What is nortriptyline contraindicated with?
People with cardiac issues
Which smoking cessation drugs should avoid in people with hepatic issues? Renal issues?
Nortriptyline is metabolized by the liver. Bupropion and varenicline are metabolized by the kidney. Clonidine should have lower doses initially in really impaired patients.
What is the MOA of clonidine?
It is a centrally acting alpha 2 agonist
What else will clonidine do besides help with smoking cessation?
Lower blood pressure
What are important counseling points about clonidine?
Do not operate heavy machinery. Do not abruptly discontinue.
If a person smokes more than 10 cigarettes a day, what strength patch should they start on?
The 21mg patch daily. If less than 10 cigarettes/day then start on 14mg patch daily.
If a person used more than 25 cigarettes daily or their time to first cigarette was less than 30 minutes after waking, what strength gum or lozenge should they use? Less than 25 daily?
More than 25 daily = start on 4mg
Less than 25 daily = 2mg
What forms of NRT are there?
Patches Gum Lozenge Inhaler Nasal spray
When is the best time to start medications to help in nicotine cessation?
1 week before the quit date
How many cigarettes are in a pack?
20
What therapy is recommended if a person has mild to moderate alcohol withdrawal? What side effects will they experience?
Supportive care, close monitoring (in hospital) and thiamine. Increased anxiety and heart rate.
What therapy is recommended with severe alcohol withdrawal?
- Benzodiazepines are primary treatment to reduce withdrawal, and reduce severity and incidence of seizures (lorazepam and oxazepam most often used).
- Thiamine prevents Wernicke-Korsakoff syndrome
- Adjunctive therapy (carbamazepine, beta blockers, clonidine, antipsychotics)
What is Wernicke-Korsakoff?
Confuse, ataxia (inability to move), and nystagmus (jerky eye movement). Korsakoff dementia is irreversible. Any sign of delirium treat with thiamine.
How do you maintain abstinence in alcohol use disorder?
Meds and non-pharm treatment
What is the goal of maintenance therapy in alcohol use disorder?
- reduce cravings
- reduce withdrawal symptoms
- decrease impulsive or situational alcohol use
- lengthen periods of abstinence
- Prevent slip into relapse
- support psychosocial treatment
What medications are used in maintenance therapy for alcohol UD?
Naltrexone, acamprosate, or disulfiram
When should acamprosate be used?
- When patients have a goal of abstinence.
- Cannot have renal impairment.
- Depression and suicidality are things to be monitored
What is the most common side effect of acamprosate?
Diarrhea
When should naltrexone be used?
- Stops cravings, prevents risk of relapse.
- Prevents opioid receptor-mediated euphoric effects of alcohol.
- Need to have 3-7 abstinent days before initiation
- Caution is hepatotoxicity
- Cannot take with opiates
When should disulfiram be used?
- When there is no alcohol involved for 2 weeks
- Irreversibly binds to ALDH
What is a common side effect of disulfiram?
Garlic, metallic aftertaste. And of course the disulfiram reaction if any alcohol is consumed (tachycardia, flushing, vomiting, hypotension, etc.)
Which alcohol UD maintenance med can you use in liver disorder?
Acamprosate
Which benzodiazepine would be best to use in severe alcohol UD withdrawal in a patient with liver disorder?
lorazepam, because it is not metabolized by the liver
What would you do in mild to moderate opiate UD intoxication?
Does not usually require medication. Short acting opiate: observe and release after a few hours. Long-acting, requires inpatient observation for 24-48 hours.
What would you do in severe opiate UD intoxication/overdose?
Naloxone.
What are common adverse effects of naloxone?
Increased or decreased blood pressure, increased heart rate, sweating, n/v
It is a good idea to stop opioids using medical withdrawal?
- Yes, if you have a short history of opioid abuse or there is no maintenance treatment available. It is still extremely uncomfortable, but is not life-threatening.
What kind of medical withdrawal options are available for stopping opioids?
- Clonidine and abrupt d/c of opioids
- Clonidine-naltrexone detox (needs 8 hours observation)
- Methadone substitution
- Buprenorphine substitution
- Buprenorphine w/ naloxone
What is clonidine used for?
- Medical withdrawal from opiates
- It decreases the withdrawal symptoms of N/V/D, not insomnia or cravings
- SE of hypotension (alpha2 agonist: blocks baroreflex)
- do not abruptly discontinue (rebound hypertension)
What is first-line therapy for opioid UD?
An opiate agonist like methadone or buprenorphine/naloxone.
What should you use in pregnancy for opioid use-disorder?
Buprenorphine by itself.
What meds should you use as induction or maintenance therapy in opioid UD?
Short-acting meds: Suboxone for induction and maintenance
Long-acting opioids: Buprenorphine for induction and suboxone for maintenance.
What is a serious condition that it is contraindicated with methadone use?
Any underlying cardiac conditions. An AE of methadone is that it can increase the QT interval.
What opioid agonist/partial agonist has poor oral availability?
Buprenorphine (a partial mu agonist and kappa antagonist) in combination with suboxone has poor oral availability and good sublingual bioavailability.
